Abstracts

AAP-Section on Perinatal Pediatrics

Abstract

Journal of Perinatology (2002) 22, 594-622 doi:10.1038/sj.jp.7210812

SECTION ON PERINATAL PEDIATRICS, 2002 AMERICAN ACADEMY OF PEDIATRICS ¾ NATIONAL CONFERENCE AND EXHIBITION, OCTOBER 19 TO 20, BOSTON, MA ORGANIZATION OF NEONATAL/PERINATAL TRAINING PROGRAM DIRECTORS (ONTPD)

Session H707

Friday, October 18, 2002

1:00 to 5:00 PM

William Truog, MD, Chairman

SECTION ON PERINATAL PEDIATRICS

Session H117

Saturday, October 19, 2002

8:00 AM to 5:30 PM

8:00 AM

Welcome

Gerald Merenstein, MD

8:10-9:55 AM

Abstract Presentations

Session 1 (*Indicates candidate for Young Investigator Awards)

Moderator: TBA

8:10 AM

Effects of Dexamethasone and Celecoxib on Newborn Rabbit Lung Vascular Endothelial Growth Factors and Their Receptors During Hyperoxia

Houchang D. Modanlou, MD, Francis Tambunting, MD, Kay D. Beharry, BSc, Aamir Akmal, MD, and Arwin Valecia, MD. Pediatrics, University of California at Irvine, Irvine, CA

8:25 AM

*Characterization of P2Y Purine Receptors in Fetal Lamb Pulmonary Circulation

Indira D. Chandrasekar, MD, Ivane Bakhutashvili, MD, and Girija G. Konduri, MD. Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI

8:40 AM

*Long-term Statement and Wide Distribution of Serotype 5 Adeno-Associated Virus (AAV5) Achieved With Perfluorocarbon-aided Delivery

Mary E. Brindle, MD^1,2 Michael Bachmann, PhD¹, Erik D. Skarsgard, MD², and Christopher H. Contag, PhD¹. ¹Pediatrics, Immunology, Stanford University, Palo Alto, CA; and ²Pediatric Surgery, University of British Columbia, Vancouver, BC, Canada

8:55 AM

*Role of Repellant Signaling in Postnatal Murine Lung Development

Parthak Prodhan, MD>¹, Mark A. Anselmo, MD², Katsumi Komatsuzaki, MD, PhD², Sussie T. Dalvin, MSc², Jeremy T. Aiden, MD³, Jay J. Schnitzer, MD, PhD³, and T. Bernard Kinane, MD². ¹Pediatric Critical Care; ²Pediatric Pulmonary; and ³Pediatric Surgery, Massachusetts General Hospital for Children, Boston, MA

9:10 AM

*Muscle Protein Synthesis Regulation in Neonates

Pamela MJ O'Connor, MB, BCh, BAO¹, Agus Suryawan, PhD¹, Jill A. Bush, PhD¹ Hanh V. Nguyen, BSc¹, Scot R. Kimball, PhD², and Teresa A. Davis, PhD¹. ¹USDA/ARS Children's Nutrition Research Center, Pediatrics, Neonatology, Baylor College of Medicine, Houston, TX; and ²Cellular and Molecular Physiology, Pennsylvania State University College of Medicine, Hershey, PA

9:25 AM

*Bone Marrow Stem Cells Contribute to Vascular Regeneration Following Toxin-Induced Hepatic Injury

Kirsten A. Kienstra, MD¹, Susan K. Majka, PhD^1,2, and Karen K. Hirschi, PhD^1,2. ¹Department of Pediatrics, Baylor College of Medicine, Houston, TX; and ²Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX

9:40 AM

Placing Infants <29 Weeks' Gestation in Polyurethane Bags After Birth to Reduce Hypothermia

John E. Wimmer, Jr., MD¹, Robin B. Knobel, MSN², Carla Ahearn, MSN³, Marie Morton, ADN³, and Don Holbert, PhD⁴. ¹Pediatrics, Brody School of Medicine East Carolina University, Greenville, NC; ²School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC; ³Neonatal Department, University Health Systems/Children's Hospital, Greenville, NC; and ⁴Biostatistics, East Carolina University, Greenville, NC

9:55 AM

Break

10:15 AM

Neonatal Tetanus ¾ A Continuing Problem in Developing Countries

Idowu O. Oladiran, MBBS¹, Donald E. Meier, MD, FAAP^1,2, David A. OlaOlorun, MBBS¹, and Daniel A. Gbadero, MBBS¹. ¹Pediatrics and Surgery, Baptist Medical Center, Ogbomoso, Oyo, Nigeria; and ²Surgery, Children's Medical Center, Dallas, TX

10:30 AM

*Association of PCR Detection of Ureaplasma Urealyticum in Endotracheal Aspirates of Very Low Birth Weight Infants With Incidence of Chronic Lung Disease of Prematurity

Tarah T. Colaizy, MD¹, Gary Sexton, PhD², Elaine Walker, RRT¹, Spencer Watson¹, and De-Ann M. Pillers, MD, PhD, FAAP¹. ¹Pediatrics, Oregon Health and Science University, Portland, OR; and ²Clinical Research Center, Oregon Health and Science University, Portland, OR

10:45 AM

*Regulation of Specific Immune Response to Microbes in the Neonate

Mohamed Mohamed, MD, Maciej Simm, BS, Mirjana Nesin, MD, and Susanna Cunningham-Rundles, PhD. Department of Pediatrics, Cornell University Weill Medical College, New York, NY

11:00 AM

*Fluconazole Prophylaxis Against Systemic Candidiasis After Colonization: A Randomized, Double-Blinded Study

Cynthia Cabrera, MD, Melissa Frank, PharmD, Danene Carter, RN, and Jatinder Bhatia, MD. Section on Neonatology/Department of Pediatrics, Medical College of Georgia, Augusta, GA

11:15 AM

*Intestinal Permeability and Inflammation but Not Bacterial Translocation are Increased in Parenterally Versus Enterally Fed Neonatal Pigs

Ketan Kansagra, MD¹, Barbara Stoll, PhD², Cheryl Rognerud³, Harri Niinikoski, MD², Ching-Nan Ou, PhD³, Roger Harvey, PhD⁴, and Douglas Burrin, PhD². ¹Newborn Section, Department of Pediatrics, Baylor College of Medicine, Houston, TX; ²Department of Pediatrics, USDA/ARS/Baylor College of Medicine, Houston, TX; ³Department of Pathology, Baylor College of Medicine, Houston, TX; and ⁴Food and Feed Safety Unit, USDA/Texas A&M University, College Station, TX

11:30 AM

*Cardiac Channel Mutations in Sudden Infant Death Syndrome: A Population-based Molecular Autopsy Study

Michael J. Ackerman, MD, PhD¹, David J. Tester, BS¹, Carla M. Bell¹, William Q. Sturner, MD², and Jeffrey A. Towbin, MD³. ¹Pediatric and Adolescent Medicine/Pediatric Cardiology, Mayo Clinic/Mayo Foundation, Rochester, MN; ²Medical Examiner's Office, Arkansas State Crime Laboratory, Little Rock, AR; and ³Pediatrics and Cardiovascular Sciences, Baylor College of Medicine, Houston, TX

11:45 AM

Intrauterine Myelomeningocele Repair: Effect on the Short-Term Complications of Prematurity

A.H. Hamdan, MBBCh, MD, W. Walsh, MD, J.P. Bruner, MD, and Noel Tulipan, MD. Divisions of Neonatology, Perinatology and Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, TN

12:00 PM

The Thomas E. Cone, Jr. Lecture

Tetanus of the Newborn: What the Chinese Knew 2000 Years Ago

Dr. Larry Gartner, History Committee Chair

Supported by a grant from Ross Products Division, Abbott Laboratories

1:00 PM

Poster Session and Luncheon

Advanced registration is required

Posters will be available for viewing from 1:00 to 7:00 PM. Authors will be present beside their posters from 1:00 to 2:00 PM (lunch) and from 5:30 to 7:00 PM (reception)

Poster presentations

(*indicates candidate for Young Investigator Awards)

(P1)

Newborn Length of Stay, Health Care Utilization, and the Effect of Minnesota Legislation

Diane J. Madlon-Kay, MD¹ and Terese A. DeFor, MS². ¹Ramsey Family and Community Medicine Residency Program, St Paul, MN; and ²HealthPartners Research Foundation, Bloomington, MN

(P2)

Postpartum Interviews: Factors Influencing Patients' Learning and Satisfaction

Ximena L. Valdes, MD¹, Mirzada P. Kurbasic, MD¹, Barbara S. Whitfill¹, and Daniel I. Sessler, MD². ¹Department of Pediatrics, University of Louisville, Louisville, KY; and ²Outcomes Research Institute, University of Louisville, Louiseville, KY

(P3)

Health Problems of Home-Born Infants

Guner Karatekin, MD¹, Ozgul Salihoglu, MD¹, Haydar Sur, MD², Fusun Okan, MD¹, Sinan Uslu, MD¹, and Asiye Nuhoglu, MD¹. ¹Department of Neonatology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey; and ²Faculty of Health Education, Marmara University, Istanbul, Turkey

(P4)

*The Timing of Clamping the Umbilical Cord: Is it Important?

Alberto Orozco, MD, FAAP^1,2 and Sergio Graham, MD, DABP^1,2. ¹Department of Neonatology, Hospital Angeles del Pedregal, Mexico, DF, Mexico; and ²Facultad Mexicana de Medicina, Universidad La Salle, Mexico, DF, Mexico

(P5)

Neonatal Autopsy: Does it Add to Our Clinical Diagnoses?

Wendy J. Kowalski, MD¹, David Paul, MD², Jay S. Greenspan, MD¹, and Lazaros Kochilas, MD¹. ¹Pediatrics, Thomas Jefferson University, Philadelphia, PA; and ²Pediatrics, Christiana Care, Newark, DE

(P6)

Is Brazilian Neonatal Resuscitation Training of Ventilation Adequate?

Ruth Guinsburg, MD, M. Fernanda B. Almeida, MD, Jose O. Costa, MD, Lincoln MS Freire MD, and Instructors of Neonatal Resuscitation Program. Brazilian Society of Pediatrics, Brazil

(P7)

Brazilian Neonatal Resuscitation Program: Factors That Interfere With Knowledge Gain After Training

M. Fernanda B. Almeida, MD, Ruth Guinsburg, MD, Jose O. Costa, MD, Lincoln MS Freire, MD, and Instructors of the Neonatal Resuscitation Program. Brazilian Society of Pediatrics, Brazil

(P8)

Instruction of Pediatric Housestaff in Neonatal Resuscitation: Benefit of a Refresher Course

Odell Wilson, MD, Lori A. Sielski, MD, Joseph H. Schneider, MD, Tiffany M. McKee-Garrett, MD, Lori J. Hull, MD, and Carciolo J. Hernandes, MD. Pediatrics, Baylor College of Medicine, Houston, TX

(P9)

Neonatal Skin Care: Clinical Outcomes of the AWHONN/NANN Evidence-Based Clinical Practice Guideline

Carolyn H. Lund, RN, MS¹, Jason W. Osborne, PhD², Joanne Kuller, RN, MS¹, Alfred T. Lane, MD, FAAP³, Judy W. Lott, RNC, DNS⁴, and Deborah A. Raines, PhD, RNC⁵. ¹Intensive Care Nursery, Children's Hospital Oakland, Oakland, CA; ²Department of Educational Psychology, University of Oklahoma, Norman, OK; ³Department of Dermatology, Stanford Hospital, Palo Alto, CA; ⁴College of Nursing and Health, University of Cincinnati, Cincinnati, OH; and ⁵College of Nursing, Florida Atlantic University, Davie, FL

(P10)

Oromotor Dysfunction in Neonates: A Feeding Strategy

Andrea Glover, MEd², Theresa Lusk, MEd², Amy Knight, RD¹, Mary Mark Perkins, PT², Chantrapa Bunyapen, MD, FAAP¹, and Jatinder Bhatia, MD, FAAP¹. ¹Section of Neonatology/Department of Pediatrics; and ²Rehabilitation, Medical College of Georgia, Augusta, GA

(P11)

Early Measurement of End-Tidal Carbon Monoxide (ETCOc) in Term Neonates

Marguerite Herschel, MD. Pediatrics, University of Chicago, Chicago, IL

(P12)

Blood Transfusion Practice Variability in Very Premature Infants

Dale Gerstmann, MD, Barry Bloom, MD, FAAP, and Reese Clark, MD, FAAP. Center for Research and Education, Pediatrix/Obstetrix Medical Group, Sunrise, FL

(P13)

Transfusion Clinical Practice and Erythropoietin Usage in Very Premature Infants

Dale Gerstmann, MD, Barry Bloom, MD, FAAP, and Reese Clark, MD, FAAP. Center for Research and Education, Pediatrix/Obstetrix Medical Group, Sunrise, FL

(P14)

*A Method for Determining Whether Transcutaneous Bilirubin Measurements Can Replace Serum Bilirubin Measurements: A Model for New Technology Evaluation

Joseph H. Schneider, MD, MBA. Pediatrics, Baylor College of Medicine, Houston, TX

(P15)

Neonatal Mortality Attributed to Kernicterus in USA

Vinod K. Bhutani, MD, and Lois H. Johnson, MD. Newborn Pediatrics, Pennsylvania Hospital, Philadelphia, PA

(P16)

*Electroencephalogram in Infants Following Extracorporeal Membrane Oxygenation: Are They Necessary?

John H. Bartley, MD¹, Yong Park, MD², Chantrapa Bunyapen, MD¹, and Jatinder Bhatia, MD, FAAP¹. ¹Department of Pediatrics/Section of Neonatology; and ²Department of Neurology, Medical College of Georgia, Augusta, GA

(P17)

*Prenatal Molecular Diagnosis of Congenital Long QT Syndrome

David J. Tester, BS¹, Jorge McCormack, MD², and Michael J. Ackerman, MD, PhD¹. ¹Pediatric and Adolescent Medicine/Pediatric Cardiology, Mayo Clijnic, Rochester, MN; and ²Pediatric Cardiology, Pediatric Cardiology Associates, University of South Florida, St. Petersburg, FL

(P18)

Effect of Fetal Betamethasone Exposure on Left Cardiac Function of Very Low Birth Weight Infants (VLWBI)

Takehiko L. Yokoyama. Pediatrics, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan

(P19)

*pH Does Not Affect Nitric Oxide Synthase Activity and Expression in Bovine Aortic Endothelial Cells

Sandor Nagy, MD¹, M. Brennan Harris, PhD², Hong Ju, PhD², Jatinder Bhatia, MD¹, and Richard C. Venema, PhD^1,2. ¹Section of Neonatology, Department of Pediatrics; and ²Vascular Biology Center, Medical College of Georgia, Augusta, GA

(P20)

*Neonatal Tidal Volume on High Frequency Oscillatory Ventilation Using Hot-Wire Anemometry

W.J. Sturtz, S.M. Touch, R.G. Locke, J.S. Greenspan, and T.H. Shaffer. Neonatology, Thomas Jefferson University Hospital, Philadelphia, PA

(P21)

Late Surfactant Administration in Rescue Therapy Does Not Affect Outcome

Fernando Vega, MD, Ines E. Garcia, MD, FAAP, Lourdes Garcia, MD, FAAP, and Marta Valcarcel, MD, FAAP. Department of Pediatrics, Neonatology Section, University of Puerto Rico School of Medicine, San Juan, PR

(P22)

*Early Indomethacin Prophylaxis is Associated With an Increased Risk of Bronchopulmonary Dysplasia in Extremely Low Birth Weight Infants

Drifa Freysdottir, MD, Suzanne E. Hegemier, RN, and Patricia L. Ramsey, MD. Department of Pediatrics, Baylor College of Medicine, Houston, TX

(P23)

Indomethacin Therapy in Premature Infants: Effectiveness of a Dosing Strategy Based on a Single Measurement of a Second Dose Peak Serum Indomethacin Concentration

Donough J. O'Donovan, MD, Caraciolo J. Pernandes, MD, Ngoc-Yen Nguyen, PharmD, Karen Adams, RN, and James M. Adams, MD. Pediatrics, Baylor College of Medicine, Houston, TX

(P24)

Evaluation of a Neonatal Vancomycin Dosage Regimen

Marilyn A. Fisher, MD¹, Amy L. Mitchell, PharmD^1,2, Katie L. Vo, PharmD³, and Manuel Sandoval, PhD¹. ¹Pediatrics, Albany Medical College, Albany, NY; ²Pharmacy, Albany Medical Center, Albany, NY; and ³IDEC Pharmaceuticals, San Diego, CA

(P25)

*Increased IL-6, IL-1, and IL-8 in Cord Blood of Term Neonates Compared to Adult Controls in Response to Bacterial Antigens

Mohamed A. Mohamed, MD¹, Florencia Cruz, MD¹, Charles Dean, BS², Susanna Cunningham-Rundles, PhD¹, and Mirjana Nesin, MD¹. ¹Department of Pediatrics, Cornell University Weill Medical College, New York, NY; and ²Wyeth Research, Pearl River, NY

(P26)

Late-Onset Coagulase Negative Staphylococcus Sepsis in Very Low Birth Weight Infants

E.I. Ahmed, MD, A.A. Johnson, D. Kumar, MD, MRCP, D.M. Super, MD, MPH. N. Abughali, MD, and F.A. Saker, MD. Pediatrics, MetroHealth Medical Center, Cleveland, OH

(P27)

Neonatal Morbidity and Mortality for India and the Role of Bacterial Sepsis (in 2000)

Vinod K. Paul, MD and Ashok K. Deorari, MD. On behalf of National Neonatology Forum, India

(P28)

Fungal Infection in the Very and Extreme Low Birth Weight Infant

Luis M. Rodriguez, MD, Ines E. Garcia, MD, FAAP, Janessa Vazquez, BS, Lourdes Garcia, MD, FAAP, and Marta Valcarcel, MD, FAAP. Neonatology Section, Department of Pediatrics, University of Puerto Rico School of Medicine, San Juan, PR

(P29)

Comprehensive Infection Control Measures Reduce Nosocomial Infection Rates in a Neonatal Intensive Care Unit

Robert L. Schelonka, MD, FAAP, Susan Scruggs, RN, Kimberly Nichols, RN, Reed A. Dimmitt, MD, FAAP, and Waldemar A. Carlo, MD, FAAP. Pediatrics, University of Alabama at Birmingham, Birmingham, AL

(P30)

*Mild to Moderate Renal Dysfunction Does Not Alter Therapeutic Levels of Caffeine in Neonates Treated for Apnea of Prematurity

Cynthia Cabrera, MD, Melissa Frank, PharmD, Danene Carter, RN, and Jatinder Bhatia, MD. Section of Neonatology/Department of Pediatrics, Medical College of Georgia, Augusta, GA

(P31)

A prospective Study Evaluating the Effect of Immunizations on Apnea and Bradycardia (A&B) Spells in Premature Infants

Richard C. Lussky, MD, Michelle L. Sneen, Raul F. Cifuentes, MD, Karen E. Kaestner, MT(ASCP), Debra K. Abrams, MR(ASCP), and Joni S. Geppert, MPH. Department of Pediatrics, Hennepin County Medical Center, Minneapolis, MN

(P32)

Palivizumab Prophylaxis of RSV Disease ¾ Results of 5097 Children - the 2001 to 2002 Outcomes Registry

Mark Hudak, MD and the Palivizumab Outcomes Registry. University of Florida, Jacksonville, FL

(P33)

Safety Surveillance in Children Treated With Palivizumab (PLV)

Edward M. Connor, MD, FAAP¹, John B. McClain, MD², Mark Sorrentino, MD, FAAP³, Robert L. Hirsch, PhD³, and Franklin H. Top, Jr., MD, FAAP¹. ¹Clinical Development; ²Pharmacovigilance; and ³Medical Affairs, MedImmune, Gaithersburg, MD

(P34)

*Distinctive Distribution of Pathogens Associated With Peritonitis in Neonates With Focal Intestinal Perforation Versus Necrotizing Enterocolitis

Eric W. Coates, MD¹, M. Gary Karlowicz, MD¹, Daniel P. Croitoru, MD², and E. Stephen Buescher, MD¹. ¹Pediatrics, Eastern Virginia Medical School, Norfolk, VA; and ²Surgery, Eastern Virginia Medical School, Norfolk, VA

(P35)

The Role of Adaptive Mucosal Immunity in Ischemia/Reperfusion Intestinal Injury

Reed A. Dimmitt, MD, FAAP¹, Harry W. Schroeder, MD, PhD², Yuki Hammers, MD³, and Robert L. Schelonka, MD, FAAP¹. ¹Pediatrics, University of Alabama at Birmingham, Birmingham, AL; ²Medicine and Microbiology, University of Alabama at Birmingham, Birmingham, AL; and ³Pathology, University of Alabama at Birmingham, Birmingham, AL

(P36)

Identifying Dysfunctional K⁺ Transport in Erythrocytes of Extremely Low Birth Weight Infants With Nonoliguric Hyperkalemia

Isabel Basaldu-Prado, MD, M. Ahsan Choudary, and Robert Castro, MD. Pediatrics, University of Texas Health Science Center, San Antonio, TX

(P37)

*Toward a Standard Protocol for Glucometer Series in Term LGA Neonates

Mihail M. Subtirelu, MD and Yves G. Verna, MD. Pediatrics, Bronx-Lebanon Hospital Center, Bronx, NY

(P38)

Venous Versus Capillary Sampling for Determination of Plasma Glucose Concentrations in the Newborn

Madhava R. Beeram, MD, Brown Gary, MD, and Cheryl Laughran, MSN. Division of Neonatology, Scott and White Clinic/Texas A&M College of Medicine, Temple, TX

(P39)

Antenatal Diagnosis of Surgically Correctable Anomalies: Are Repeated Consultations Anxiety-Inducing or Anxiety-Reducing?

Lucia Aite, MD, Alessandro Trucchi, MD, Antonella Nahom, MD, Antonio Zaccara, MD, and Pietro Bagolan, MD. Newborn Surgery Unit, Bambino Gesu Children's Hospital, Rome, Italy

(P40)

Characteristics of Congenital Cystic Adenomatoid Malformations Associated With Nonimmune Hydrops and Outcome

KuoJen Tsao, MD¹, Lan Vu, BA¹, Hanmin Lee, MD¹, Diana L. Farmer, MD¹, Craig T. Albanese, MD¹, Michael R. Harrison, MD¹, and Ruth B. Goldstein, MD². ¹Surgery, University of California, San Francisco, San Francisco, CA; and ²Radiology, University of California, San Francisco, San Francisco, CA

(Underline denotes presenting author)

NEONATAL HEALTH AND SOCIETY: INNOVATIVE PROGRAMS TO REDUCE WORLDWIDE INFANT MORTALITY

Joint Session with Section on International Child Health

Moderators: Gerald Merenstein and Karen Olness

2:00-2:45 PM

Report card on Neonatal Health

Mary Ellen Avery, MD

2:45-3:05 PM

Sustainable Regionalized Perinatal Care: Level I to level III in 2 Years

Janusz Gadzinowsk, MD, PhD (Poland)

3:10-3:30 PM

Sustainable Community-Based Program: Effective Utilization of Limited Resources

Meharban Singh, MD (India)

3:30-4:00 PM

Break

4:00-4:20 PM

Perinatal HIV: National Achievements and Challenges

Philippa Musoke, MD (Uganda)

4:25-4:45 PM

Neonatal Resuscitation: Cultural Adoptions of AAP Neonatal Resuscitation Program

Wei Ku-Lin, MD (China)

4:45-5:05 PM

Latin Perinatal-Neonatal Care

Jorge Cesar Martinez, MD (Buenos Aires)

5:05-5:30 PM

"It's a Small World"

Panel Discussion

5:30-7:00 PM

Poster Reception With the Section on International Child Health

SECTION ON PERINATAL PEDIATRICS

Session H215

Sunday, October 20, 2002

8:00 AM to 4:30 PM

8:00-9:00 AM

Meet the Fetus and Newborn Committee

COFN Highlights ¾ Lillian Blackmon, MD, FAAP, Ann Stark, MD, FAAP, James Lemons, MD, FAAP

STATE OF THE ART LECTURE SERIES

9:00-9:10 AM

Introduction: Neonatal Health and Family

9:10-9:40 AM

Patient Safety and Sentinel Events

Charles Homer, MD, FAAP

9:40-10:10 AM

Neonatal Brain Damage

Susan Sheridan

10:10-10:40 AM

Break

10:40-11:10 AM

Neonatal Blindness

Tina Fiorentino

11:10 AM-12 PM

Role of the Family as Consumers, Advocates, Home-Based Care Providers

Panel Discussion

12:00-12:30 PM

Presentation of the Neonatal Education Award, the Landmark Award, and the Young Investigator Awards

Neonatal Education Award Recipient: Jack Sinclair, MD, FAAP

Supported by a grant from Mead Johnson Nutritionals

Young Investigator Award: TBA

Supported by a grant from Mead Johnson Nutritionals

Landmark Award Recipient: Marshall Klaus, MD, FAAP

Supported by a grant from Natus Medical

12:30-1:00 PM

Section Business Meeting

1:00-2:00 PM

Lunch Break

2:00-2:45 PM

Recent Advances: Biology and Physiology of Airway Smooth Muscle

Thomas Shaffer, III, PhD

2:45-3:30 PM

Reactive Airway Disease With BPD

Richard Martin, MD, FAAP

3:30-3:45 PM

Break

3:45 PM

Virginia Apgar Award Presentation and Reception

Recipient: Avroy Fanaroff, MD, FAAP

Supported by a grant from Ross Products Division, Abbott Laboratories

Session 1 2002 ANNUAL MEETING PLATFORM PRESENTATIONS SATURDAY, OCTOBER 19, 2002 8:10 AM EFFECTS OF DEXAMETHASONE AND CELECOXIB ON NEWBORN RABBIT LUNG VASCULAR ENDOTHELIAL GROWTH FACTORS AND THEIR RECEPTORS DURING HYPEROXIA

H.D. Modanlou, F. Tambunting, K.D. Beharry, A. Akmal, A. Valecia. University of California at Irvine, Irvine, CA

Dexamethasone (Dex) is used to decrease the effects of hyperoxia (O₂) but it may interfere with normal pulmonary angiogenesis. We examined the effects of Dex and Celecoxib (Cel), a selective COX-2 inhibitor, on VEGFs and their receptors in newborn rabbits lung exposed to O₂. Rabbit pups were exposed to room air (RA) or O₂ (80-100%) for 4 days and were administered saline (Sal), Dex, Cel, or vehicle (Veh). Eight groups were sacrificed following O₂ or RA, and eight groups were placed in RA for 5 days following O₂ or in RA. Lungs were collected for mRNA expression of VEGFs (V121, V165, and V189) and VEGF receptors (KDR/Flk-1 and Flt-1). O₂ resulted in three- to five-fold decreases in all VEGFs in the Sal-treated (p<0.05 to p<0.01) groups, and persisted during O₂/RA (five- to seven-fold, p<0.05 to p<0.001). Similarly, O₂ resulted in decreases in V121 (four-fold, p<0.001) and V165 (three-fold, p<0.01) in the Veh-treated groups. Upon recovery in RA, no difference in V121 was observed, whereas decreases were noted in V165 (three-fold, p<0.01) and V189 (four-fold, p<0.05) mRNA expression. Dex and Cel appeared to preserve VEGFs during O₂. However, recovery in RA decreased V121 (two-fold, p<0.05) and V189 (three-fold, p<0.01) with Dex, whereas decreases in V165 (three-fold, p<0.001) and V189 (four-fold, p<0.001) were noted with Cel treatment. O₂ suppressed KDR/Flk-1 mRNA expression in the Sal-treated (p<0.01), Dex-treated (p<0.05), and Veh-treated (p<0.01) groups, whereas Flt-1 was suppressed in the Sal- and Dex-treated groups only (p<0.01). Cel during O₂ resulted in increased KDR/Flk-1 (p<0.01) mRNA expression. KDR/Flk-1 and Flt-1 mRNA were minimally expressed in RA.

These data demonstrate that although Dex treatment during hyperoxia may preserve VEGFs, it does not have a similar effect on their receptors. In contrast, Cel sparing the VEGFs and their receptors during hyperoxia may indicate normal lung angiogenesis.

8:25 AM CHARACTERIZATION OF P2Y PURINE RECEPTORS IN FETAL LAMB PULMONARY CIRCULATION

I.D. Chandrasekar, I. Bakhutashvili, G.G. Konduri. Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI

Activation of P2 purinergic receptors by ATP plays an important role in pulmonary vasodilation at birth. Purine nucleotides (ATP, ADP, and AMP) cause vasodilation by stimulating specific receptors on endothelial and smooth muscle cells.

P2 receptors are classified into ionotropic P2X and G-protein coupled P2Y receptors. P2Y receptors are classified into P2Y1, P2Y2, P2Y4, and P2Y6 subtypes based on sensitivity to purines and pyramidines (UTP-UMP). Objective is to identify P2Y receptors mediating vasodilator effects of purines and pyrimidines.

Effects of purine and pyrimidine nucleotides were tested in isolated pulmonary artery (PA) rings mounted in tissue bath and preconstricted with U46619. Relaxation response to nucleotides was determined at 10^-7 to 10^-3 M concentration. Gene expression of P2Y receptor subtypes was determined in PAs and PA endothelial cells (PAECs) by RT-PCR. Target cDNA was amplified using gene-specific oligonucleotide primers for P2Y receptors. Amplification products were resolved on agarose gel by electrophoresis, identified by a molecular size standard, and confirmed by direct sequencing.

Fetal lamb PA rings showed significant relaxation to purines and UTP but not UDP and UMP. The agonist profile ATP>UTP>ADP>AMP suggests that vasodilation is caused by P2Y1 (purine selective) and P2Y2 (dual selective) receptors. RT-PCR has demonstrated expression of P2Y1, P2Y2, and P2Y4 receptors but not P2Y6 receptors in PAECs and PAs.

G-protein coupled P2Y1, P2Y2, and P2Y4 receptors are expressed in fetal PAECs. The functional response of fetal PAs correlates with the expression of P2Y1 and P2Y2 receptors. The lack of response to UDP and UMP correlates with absence of P2Y6 receptor expression. The specific role of P2Y4 receptor remains unknown. Delineation of these receptors will facilitate investigation of their alteration in persistent pulmonary hypertension of newborn. Supported by HL57268 from NHLBI.

8:40 AM LONG-TERM STATEMENT AND WIDE DISTRIBUTION OF SEROTYPE 5 ADENO-ASSOCIATED VIRUS (AAV5) ACHIEVED WITH PERFLUOROCARBON-AIDED DELIVERY

M.E. Brindle^1,2, M. Bachmann¹, E.D. Skarsgard², C.H. Contag¹. ¹Pediatrics, Immunology, Stanford University, Palo Alto, CA; ²Pediatric Surgery, University of British Columbia, Vancouver, BC, Canada

Traditional methods of delivery of adeno-associated virus 2 (AAV2) to lung have not resulted in efficient gene transfer. AAV5, with receptor-mediated viral binding, may achieve more efficient transfection when delivered using perfluorocarbons (PFC).

rAAV5 and rAAV2 were created with a payload consisting of a fusion gene comprised of the coding sequences for luciferase and yellow fluorescent protein (YFP).

Viral vectors were delivered via tracheal injection in aqueous solution either in the presence or absence of PFC.

The spatiotemporal pattern of gene expression was followed using in vivo bioluminescent imaging. Levels of statement were quantified and expressed as photon count. Histologic localization of statement was performed using fluorescent microscopic detection of YFP. Groups of animals that received PFC-aided delivery of rAAV5 had significantly higher levels of reporter gene statement in the lungs compared to other treatment groups. The high levels of signal assessed by imaging were due to higher numbers of transfected cells around the distal airways and alveoli of mice given PFC-aided delivery of rAAV5.

PFC-aided delivery of viral vectors may result in broader distribution, and AAV5 may achieve higher levels of gene statement than the more traditional AAV2 vector (Figure 1).

8:55 AM ROLE OF REPELLANT SIGNALING IN POSTNATAL MURINE LUNG DEVELOPMENT

P. Prodhan¹, M.A. Anselmo², K. Komatsuzaki², S.T. Dalvin², J.T. Aiden³, J.J. Schnitzer³, T.B. Kinane². ¹Pediatric Critical Care; ²Pediatric Pulmonary; ³Pediatric Surgery, MassGeneral Hospital for Children, Boston, MA

Postnatal murine lung development involves interaction between the epithelium and the mesenchyme involving both attractive as well as repellant molecules. Borrowing from the developmental role of similar repulsive molecules involved in neuronal axon migration in developing nervous system, we believe that these signaling molecules may play a role in postnatal lung development by regulating cell migration. This study investigates if the repulsive receptors Robo 1 and Robo 2, and their respective ligands Slit 2 and Slit 3, are expressed in the developing murine lung.

Lung tissue from time pregnant Swiss Webster mice litters were retrieved. Total RNA was extracted from pooled samples representing postnatal days 1, 2, 3, 4, 6, 8, 10, 12, 14 and adult. RNA probes for Slit 2, Slit 3, Robo 1, Robo 2 were generated by PCR amplification using appropriate primers. Northern blotting was then carried out. Immunohistochemistry using Slit 2 and Robo 1 antibodies was carried out to evaluate localization.

Northern analysis showed that Slit 2 is strongly expressed starting postnatal day 4 and again starts decreasing by postnatal day 8 until adulthood. Slit 3 is strongly expressed starting postnatal day 8 until postnatal day 12. The Slit receptors Robo 1 and Robo 2 are strongly expressed starting postnatal day 6 until day 10. Slit 2 was localized in the mesenchyme with strongest expression in the mesenchyme surrounding the conducting airways and Robo 2 was expressed in epithelial cells in the saccular and aveolar epithelial structures.

We have demonstrated a unique pattern of expression of mRNA for receptor Robo 1, Robo 2 and its ligands Slit 2, Slit 3 in mouse postnatal lung development. Further functional studies are necessary to delineate their role in developing postnatal lungs.

9:10 AM MUSCLE PROTEIN SYNTHESIS REGULATION IN NEONATES

P.M. O'Connor¹, A. Suryawan¹, J.A. Bush¹, H.V. Nguyen¹, S.R. Kimball², T.A. Davis¹. ¹USDA/ARS Children's Nutrition Research Center, Pediatrics, Neonatology, Baylor College of Medicine, Houston, TX; ²Cellular and Molecular Physiology, Pennsylvania State University College of Medicine, Hershey, PA

Infusion of insulin and amino acids, alone or in combination, reproduces the feeding-induced stimulation of muscle protein synthesis, but whether the stimulation by each anabolic agent requires the other agent is unknown.

Somatostatin clamps were performed on fasted 7-day-old pigs (n=9-12/treatment), and infused with 0, 10, 22, 110 ng insulin/kg^0.66 per minute to achieve plasma insulin concentrations of 0, 2, 6, and 30 U/ml. Amino acids were maintained at fasting or fed levels. Muscle protein synthesis was determined with a bolus dose of [³H]phenylalanine. Translation initiation factors were analysed for content and/or phosphorylation.

Hyperinsulinemia increased protein synthesis during hypoaminoacidemia and euaminoacidemia. Hyperaminoacidemia increased protein synthesis during hypoinsulinemia and euinsulinemia. Insulin increased protein synthesis in a dose response manner, in the presence of either euaminoacidemia and hyperaminoacidemia, until maximal protein synthesis rates were achieved. At each insulin dose, hyperaminoacidemia increased muscle protein synthesis. Both insulin and amino acids increased p70S6K and 4E-BP1 phosphorylation, decreased inactive eIF4E-4E-BP1 complex content, and increased eIF4E-eIf4G active complex formation. eIF2B activity was unaffected by insulin or amino acids.

In neonates, insulin-stimulated muscle protein synthesis does not require amino acid, and amino acid-stimulated muscle protein synthesis does not require insulin. Fasting insulin levels stimulate protein synthesis. Amino acids enhance basal protein synthesis rates but do not enhance the sensitivity of muscle protein synthesis to insulin. In neonates, insulin and amino acids regulate muscle protein synthesis by modulating the availability of eIF4E for 48S ribosomal complex formation. Supported by NIH AR44474 and USDA/ARS 6250-51000-031.

9:25 AM BONE MARROW STEM CELLS CONTRIBUTE TO VASCULAR REGENERATION FOLLOWING TOXIN-INDUCED HEPATIC INJURY

K.A. Kienstra¹, S.K. Majka^1,2, K.K. Hirschi^1,2. ¹Department of Pediatrics, Baylor College of Medicine, Houston, TX; ²Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX

Vascular regeneration and perfusion are critical for tissue repair and remodeling following injury. Current evidence suggests that adult bone marrow (BM) stem cells serve as vascular cell progenitors and contribute to injury-induced neovascularization. Genetically manipulated adult stem cells may be used to promote tissue regeneration, or to deliver genes of therapeutic interest to modulate blood vessel formation and healing.

To evaluate the extent to which the highly purified side population (SP) of hematopoietic stem cells within adult BM regenerate vascular cells in a murine model of toxin-induced liver injury, adult BM SP cells were isolated from Rosa26 mice using Hoechst 33342 dye and fluorescent-activated cell sorting. Marked BM SP cells were stably engrafted into genetically matched mice. The mice then underwent allyl alcohol-induced liver injury. Serial measurements of serum transaminases and bilirubin levels were used to monitor the degree of hepatic injury. After 14 days, the livers were excised, fixed, and sectioned for immunohistochemistry. Tissue sections were strained with X-gal to localize transplanted SP cells and immunostained for endothelial-specific proteins.

Serum transaminase levels, but not total bilirubin, provided a useful measurement of allyl alcohol-induced hepatic injury. Following hepatic injury, LacZ-positive cells were found to colocalize with the endothelial cell marker, VE cadherin, indicating that BM-derived stem cells had contributed to the regeneration of vascular endothelium in response to liver injury. Control mice exhibited no evidence of LacZ-positive vessel structures.

We have demonstrated that BM SP cells serve as vascular endothelial cell progenitors in response to tissue injury. Further studies are underway to evaluate the extent to which adult stem cells contribute to neovascularization and tissue repair, and to develop strategies to optimize functional restoration of injured tissues.

9:40 AM PLACING INFANTS <29 WEEKS' GESTATION IN POLYURETHANE BAGS AFTER BIRTH TO REDUCE HYPOTHERMIA

J.E. Wimmer, Jr.¹, R.B. Knobel², C. Ahearn³, M. Morton³, D. Holbert⁴. ¹Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC; ²School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC; ³Neonatal Department, University Health Systems/Children's Hospital, Greenville, NC; ⁴Biostatistics, East Carolina University, Greenville, NC

Most infants <29 weeks' gestation were hypothermic (temperature <97.6 °F) on admission to our NICU. Therefore, we conducted a randomized, controlled trial to evaluate the effect of placing these infants in polyurethane bags in the delivery room (DR).

Infants expected to be <29 weeks' gestation were randomized to study or control groups. Study infants were placed in polyurethane bags up to their necks after delivery before being dried. They were then resuscitated per NRP guidelines and transported to the NICU, where the bags were removed and rectal temperatures were recorded. Control infants were resuscitated and transported without being placed in polyurethane bags. Environmental temperatures in the DR and NICU were recorded, as were maternal data, time of delivery, and time of NICU admission. Data were collected for secondary outcomes: survival to hospital discharge, ultrasound evidence of brain injury, duration of oxygen therapy, and length of hospitalization.

Study and control groups were comparable (see table 1). Study patients were less likely to be hypothermic on admission (44% vs 70%, p<0.01) and had higher mean admission temperatures (97.7 vs 96.8 °F, p<0.003). This effect remained significant (p<0.0001) when analysis was controlled for DR temperature. DR temperature also showed an independent, positive correlation with admission temperature. No significant differences were seen in the secondary outcomes.

Placing infant <29 weeks' gestation in polyurethane bags in the DR reduced the incidence of hypothermia and increased admission temperatures. Warmer DR temperatures enhanced this effect, and were independently associated with higher admission temperatures.

(Underline denotes presenting author)

Session 2 PERINATAL PEDIATRICS 10:15 AM NEONATAL TETANUS ¾ A CONTINUING PROBLEM IN DEVELOPING COUNTRIES

I.O. Oladiran¹, D.E. Meier^1,2, D.A. OlaOlorun¹, D.A. Gbadero¹. ¹Pediatrics and Surgery, Baptist Medical Centre, Ogbomoso, Oyo, Nigeria; ²Surgery, Children's Medical Center, Dallas, TX

In spite of immunization efforts by the WHO, neonatal tetanus (NNT) remains a global health problem. This study was undertaken to review our recent experience with NNT in an effort to formulate methods for the reduction of mortality.

This is a retrospective analysis of 77 neonates presenting with tetanus over 7 years. Management consisted of sedatives through a nasogastric tube, oropharyngeal suctioning and supplemental oxygen as needed, penicillin, antitetanus serum, and expressed breast milk. Paralysis with controlled ventilation was not an option. Statistical analysis was performed to determine significant predictors of mortality.

The 77 neonates represent 4.6% of all neonatal admissions. Only 33 (43%) mothers had any antenatal care. Sixteen (21%) received at least one dose of tetanus toxoid. Common delivery sites were: home (47%), another hospital or nursing facility (26%), and church (19%). The mean incubation period was 5.7 days, and the mean age at hospital admission 7.8 days. The mortality rate was 49%. Significant predictors of mortality were: age less than 7 days, incubation period less than 5 days, time from first symptom until hospital admission less than 2 days, spontaneous seizures on presentation to the hospital, occurrence during rainy season, maximum temperature greater than 39.4 °C, and the development of apnea or aspiration during hospitalization. NNT is common in our locale and carries a high mortality rate. Improved care with ventilators might lower mortality, but more efficient use of limited resources lies not in improved treatment but in prevention through: better distribution of tetanus toxoid to health facilities, public education in the need for vaccination, enhancement of school health programs, vaccination of all women of childbearing age at every contact with a health facility, and education of birth attendants in hygienic cord care techniques.

10:30 AM ASSOCIATION OF PCR DETECTION OF UREAPLASMA UREALYTICUM IN ENDOTRACHEAL ASPIRATES OF VERY LOW BIRTH WEIGHT INFANTS WITH INCIDENCE OF CHRONIC LUNG DISEASE OF PREMATURITY

T.T. Colaizy¹, G. Sexton², E. Walker¹, S. Watson¹, D.A.M. Pillers¹. ¹Pediatrics, Oregon Health and Science University, Portland, OR; ²Clinical Research Center, Oregon Health and Science University

The association of Ureaplasma urealyticum (Uu) colonization of the lower respiratory tract of premature infants with the development of chronic lung disease of prematurity (CLD) remains controversial. We hypothesized that Uu colonization increases risk of CLD. Previous studies may have failed to show this due to the fastidious needs of the organism in culture. We analyzed endotracheal aspirates using PCR, a highly sensitive method.

Intubated VLBW (<1500 g) infants admitted to a university-based level III NICU at <72 hours of age for 1999 to 2001 were studied. Uu was detected by PCR from endotracheal aspirates. Outcome measures included CLD (O₂ supplementation at 36 weeks CGA, at 28 days postnatal age, and at discharge). Statistical analysis was by ANOVA, Chi-square, and Fisher's exact tests. Samples were collected from 98 patients: 29 were positive for Uu by PCR (30%), 69 were negative (70%). EGA was not significantly different (Uu⁺ 26.4 vs 27.2 weeks Uu^-, p<0.09). BW was higher in the negative group (854 vs 988 g, p<0.016). At 36 weeks CGA, 23 of 26 Uu⁺ (88%), and 26 of 59 Uu^- patients (44%) were O₂-dependent, p<0.001, RR 2.15 (95% CI (1.58, 2.95). At 28 days, 26 of 26 positive (100%) and 47 of 60 negative patients (78%) were O₂-dependent, p<0.008, RR 1.27 (95% CI (1.12, 1.46). At hospital discharge, 13 of 24 positive (54%) and 17 of 59 negative patients (29%) were O₂-dependent, p<0.031.

In our population, detection of Uu in the lower respiratory tract of VLBW infants by PCR is a significant risk factor for development of CLD as defined by O₂ dependency at 28 days, 36 weeks, and hospital discharge. Further studies using sensitive detection methods are needed to determine the contribution of this organism to the pathogenesis of CLD.

10:45 AM REGULATION OF SPECIFIC IMMUNE RESPONSE TO MICROBES IN THE NEONATE

M. Mohamed, M. Simm, M. Nesin, S. Cunningham-Rundles. Department of Pediatrics, Cornell University Weill Medical College, New York, NY

Neonatal host defense against bacterial infection is initially dependent upon response of the innate immune system, which regulates evolution of the T-cell adaptive response. To study the first phase of this process, we are evaluating the relative response of memory and naive T cells and subsets of natural killer (NK) cells from cord blood of healthy term infants to specific microbial activators, L. plantarum 299v (Lp), S. epidermidis (S. epi), Group B Streptococcus (GBBS), and Escherichia coli compared with response to mitogen (PHA-L).

Cord blood was diluted in RPMI 1640 and exposed to different activators and cultured for 4 or 18 hours at 37 °C in a humidified incubator with 5% CO₂ and then assessed for intracellular interferon gamma (IFN-gamma) production and upregulation of CD69 using three fluorochrome detection, respectively, by flow cytometry.

Studies (n=10) have shown that cord CD3⁺ CD4⁺ and CD8⁺ T cells were predominately naive (CD45RA) and CD45RA⁺ CD4⁺ and CD8⁺ cells from cord blood responded more strongly to activators (p=0.001) in comparison with CD45RO⁺ CD4⁺ and CD8⁺ cells assessed as expression of CD69 after activation. Both CD4⁺ and CD8⁺ RA⁺ cord cells responded to Lp and S. epi, but only CD8⁺ RA⁺ cells showed significant response to GBBS. In IFN-gamma, response was evaluated before and after activation with PHA-L, GBBS, and E. coli. In contrast to controls, cord lymphocytes spontaneously produced more IFN (p=0.0003), mainly from CD19⁺ B cells and NK cells. In addition, cord lymphocytes responded more strongly to GBBS but not to E. coli compared to response to PHA-L (p=0.019), which was not seen in adult controls.

Neonatal lymphocytes response to microbial activators is both qualitatively and quantitatively different from that of adults and is characterized by strong cytokine response towards selected microbes.

11:00 AM FLUCONAZOLE PROPHYLAXIS AGAINST SYSTEMIC CANDIDIASIS AFTER COLONIZATION: A RANDOMIZED, DOUBLE-BLINDED STUDY

C. Cabrera, M. Frank, D. Carter, J. Bhatia. Section of Neonatology/Department of Pediatrics, Medical College of Georgia, Augusta, GA

Nosocomial infections, including candidiasis, are an important cause of morbidity and mortality in premature infants. Prophylactic therapy with fluconazole during the first 6 weeks of life has been shown to effectively decrease fungal colonization and sepsis in these infants.

Twenty-six premature infants <34 weeks and <1500 g were enrolled. Colonization was ascertained by obtaining rectal (R), oropharyngeal (O), and tracheal (T) fungal isolates on days of life 7, 14, 21, 28, 35, and 42. Once colonization was identified, infants were randomized to receive either fluconazole (6 mg/kg) or placebo.

Thirteen infants (50%) had 19 positive fungal cultures (T=2, O=6, R=11): 14 Candida albicans, two Candida species not albicans, and one T. glabrata. One infant died prior to randomization (day 8) and two infants were withdrawn. Percentage of new positive cultures by site on days of life 7, 14, 21, and 28 were, respectively: T ¾ 6.3%, 11.1%, 0%, 0%; O ¾ 12%, 4.8%, 12.5%, 0%; R ¾ 16%, 19%, 6.3%, 14.3%. No new positive cultures were identified on days 35 and 42. Mean age of the first positive culture was 15 days (range 7-28). No systemic infection occurred in the fluconazole group (n=6) while one infant (20%) in the placebo group (n=5) developed systemic candidiasis, and later it was discovered that the mother was positive for Candida at delivery.

In contrast to previous studies where prophylaxis was initiated prior to known colonization with Candida, our study demonstrated that 48% of the infants was never colonized with Candida during the 6-week study period. Of the group colonized by day 7 and included in the study, one infant (20%) developed systemic candidiasis in the placebo group. No colonized infant in the fluconazole-treated group developed systemic infection. If confirmed in a large cohort, these data suggest that fluconazole therapy after fungal colonization may be as effective as prophylaxis initiated in the first week of life.

11:15 AM INTESTINAL PERMEABILITY AND INFLAMMATION BUT NOT BACTERIAL TRANSLOCATION ARE INCREASED IN PARENTERALLY VERSUS ENTERALLY FED NEONATAL PIGS

K. Kansagra¹, B. Stoll², C. Rognerud³, H. Niinikoski², C.N. Ou³, R. Harvey⁴, D. Burrin². ¹Newborn Section, Department of Pediatrics, Baylor College of Medicine, Houston, TX; ²Department of Pediatrics, USDA/ARS/Baylor College of Medicine, Houston, TX; ³Department of Pathology, Baylor College of Medicine, Houston, TX; ⁴Food and Feed Safety Unit, USDA/Texas A&M University, College Station, TX

A risk factor for late-onset sepsis in NICU patients is prolonged total parenteral nutrition (TPN), and many of the pathogens are considered to be "gut-derived" bacteria. In adults, TPN has been linked to increased intestinal permeability, inflammation, and bacterial translocation.

Furthermore, studies indicate that translocated bacteria may be related to sepsis in NICU patients. First, we tested whether intestinal permeability, inflammation, and bacterial translocation are increased in TPN-fed compared to enterally fed newborn piglets. Pigs were fed either TPN (n=15) or formula (ENT, n=15). After 6 days, pigs were gavaged a solution of lactulose and PEG 4000 and urine was collected for 24 hours. At 7 days, samples of blood, liver, spleen, mesenteric lymph nodes, and intestinal lumes were collected and cultured for bacteria.

Urinary recovery (% dose) of lactulose (2.93% vs 0.18%) and PEG4000 (4.27% vs 1.28%) was higher (p<0.02) in TPN versus ENT pigs. Myeloperoxidase activity (mU/mg protein) was higher in the proximal jejunum (4.6 vs 2.2) in TPN-fed compared to the enterally fed pigs. The incidence of translocation was similar (54% vs 69%) in TPN and ENT pigs. We found no relationship of permeability or inflammation to bacterial translocation.

Intestinal permeability is increased in TPN versus enteral-fed neonatal pigs; however, the incidence of bacterial translocation was not increased, nor was it correlated with permeability or inflammation. Thus, bacterial translocation and intestinal permeability are not interchangeable entities in the assessment of gut barrier function.

11:30 AM CARDIAC CHANNEL MUTATIONS IN SUDDEN INFANT DEATH SYNDROME: A POPULATION-BASED MOLECULAR AUTOPSY STUDY

M.J. Ackerman¹, D.J. Tester¹, C.M. Bell¹, W.Q. Sturner², J.A. Towbin³. ¹Pediatric and Adolescent Medicine/Pediatric Cardiology, Mayo Clinic/Mayo Foundation, Rochester, MN; ²Medical Examiner's Office, Arkansas State Crime Laboratory, Little Rock, AR; ³Pediatrics and Cardiovascular Sciences, Baylor College of Medicine, Houston, TX

The causes of sudden infant death syndrome (SIDS) remain elusive. Fatal arrhythmias secondary to cardiac channelopathies may be responsible in some cases.

Comprehensive postmortem mutational analysis of five genes causing cardiac channelopathies, KVLQT1, HERG, SCN5A, KCNE1, and KCNE2, was performed on cases of SIDS or possible SIDS identified by the Arkansas State Crime Laboratory between September 1997 and August 1999 (N=93; 59 white, 34 black). Genomic DNA was extracted from frozen necropsy tissue (heart) and subjected to mutational analysis by PCR amplification, denaturing high-performance liquid chromatography, and DNA sequencing.

Overall, 28 of 93 cases (30%; 14 white, 14 black) of SIDS possessed missense mutations in one of the five cardiac channels. Nineteen distinct missense mutations were found: KVLQT1 (two), HERG (five), SCN5A (eight), KCNE1 (two), and KCNE2 (two). However, only four decedents had putative pathogenic mutations based upon absence of the mutation in at least 400 reference alleles and/or demonstration of a functionally perturbed channel. Importantly, the remaining nonsynonymous SNPs were detected in ethnic-matched reference alleles.

Nearly one-third of this SIDS cohort had an identifiable channel mutation. However, evidence supporting a pathogenic SIDS-causing mutation is present in approximately 5% of cases. This population-based molecular autopsy establishes that mutations in cardiac ion channels may indeed cause SIDS in a small percentage of cases. In addition, this study illustrates the importance of ethnic-matched controls to avoid the erroneous assignment of novel polymorphisms as SIDS-causing mutations. Whether or not these common channel polymorphisms reduce repolarization reserve and have a role in an infant's demise requires further investigation.

11:45 AM INTRAUTERINE MYELOMENINGOCELE REPAIR: EFFECT ON THE SHORT-TERM COMPLICATIONS OF PREMATURITY

A.H. Hamdan¹, W. Walsh², J.P. Bruner³, N. Tulipan⁴. ¹Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN; ²Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN; ³Division of Perinatology, Vanderbilt University Medical Center, Nashville, TN; ⁴Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, TN

The objective was to determine whether the short-term complications of prematurity were affected by intrauterine myelomeningocele repair (IUMR).

Medical records of all infants undergoing IUMR at VUMC were reviewed. Infants born at <34 weeks' gestation were identified. Two controls were identified for each IUMR infant, matched for gestational age, sex, birth weight, and antenatal steroid. Development of respiratory distress syndrome, intraventricular hemorrhage, chronic lung disease at 28 days of age, days on ventilator, and length of stay were recorded. Results were expressed as median and interquartile ranges. Comparison of data between groups was performed using Mann-Whitney U test. Categorical data were compared using the Chi-square test; p values £0.05 were considered significant. One hundred infants underwent IUMR. Forty-four infants were born at <34 weeks' gestation. Complete data were available on 34 infants. Sixty-eight matched controls were studied. The characteristics and outcomes of both groups are shown in the tables below. Table 2, Table 3

There is no difference between the short-term complications of prematurity related to IUMR and those associated with prematurity resulting from other causes.

(Underline denotes presenting author)

POSTER PRESENTATIONS P1 NEWBORN LENGTH OF STAY, HEALTH CARE UTILIZATION, AND THE EFFECT OF MINNESOTA LEGISLATION

D.J. Madlon-Kay¹, T.A. DeFor². ¹Ramsey Family and Community Medicine Residency Program, St. Paul, MN; ²HealthPartners Research Foundation, Bloomington, MN

The purpose of this study was to describe newborn length of stay, postdischarge follow-up, and healthcare utilization in the context of Minnesota's early discharge legislation.

This was a retrospective study using claims data from a large managed care organization. A total of 22,944 term newborns born from January 1995 through February 1999 were studied. Outcome measures included: newborn length of stay, home or clinic visits within 1 week of discharge (early follow-up), immunizations within 3 months of age, readmissions within 1 month of discharge, and urgent care of emergency room visits within 2 months of discharge. The percentage of newborns with hospital stays of 2 days or more after vaginal birth increased from 48% before legislation was implemented in 1996 to 84% in the following 3 years (p=0.001). The percentage of newborns with stays of at least 4 days after cesarean birth increased from 13% to 37% during that time (p=0.001). Although the legislation mandated coverage for home health nurse visits after short stays, only 12.4% of short-stay newborns received home visits within 1 week of early discharge. Infants who received early follow-up at home or clinic were more likely to be completely immunized at 3 months of age (adjusted OR=1.09), were more likely to have an urgent care or emergency room visit within 2 months of discharge (4.6% vs 3.8%, p=0.002), and were more likely to be readmitted within a month of discharge (2.7% vs 1.0%, p=0.001).

Although implementation of Minnesota's early discharge legislation corresponded with significantly increased lengths of stay, very few infants discharged early received the postdischarge care for which coverage was mandated. Our findings indicate, however, that infants at higher risk for adverse outcomes were appropriately identified to receive early follow-up.

P2 POSTPARTUM INTERVIEWS: FACTORS INFLUENCING PATIENTS' LEARNING AND SATISFACTION

X.L. Valdes¹, M.P. Kurbasic¹, B.S.Whitfill¹, D.I. Sessler². ¹Department of Pediatrics, University of Louisville, Louisville, KY; ²Outcomes Research Institute, University of Louisville, Louisville, KY

Mothers are given important information about their babies during the postpartum interview. Interview setting and technique are believed to alter efficacy of this interaction. It is believed that postpartum interviews are most effective when both parties are seated. We therefore tested the hypothesis that postpartum women's satisfaction and learning are improved when postpartum visits are conducted by pediatricians sitting near the patient's bed rather than standing, and are further improved when female pediatricians sit on the mother's bed.

Seventy-five mothers, on their first postpartum day, were interviewed by physicians randomly assigned to: (1) sitting on the edge of the bed, near the mother's feet (Bed); (2) sitting on a chair beside the bed (Chair); or (3) standing at the foot of the bed (Standing). An investigator, blinded to physician position, subsequently evaluated maternal learning and satisfaction. Differences among position groups were compared with one-way ANOVA or Wilcoxon tests.

Potential confounding factors were evenly distributed in each group. The estimated duration of interviews was similar in each group, as was the degree of satisfaction (see table). Information retention was also similar.

Our results suggest that physicians need not make special efforts to conduct postpartum interviews in a seated position. Table 4

P3 HEALTH PROBLEMS OF HOMEBORN INFANTS

G. Karatekin¹, O. Salihoglu¹, H. Sur², F. Okan¹, S. Uslu¹, A. Nuhoglu¹. ¹Department of Neonatology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey; ²Faculty of Health Education, Marmara University, Istanbul, Turkey

This study aims to find out dimensions of health problems of hospitalized newborns whose deliveries were at home by untrained persons and to contribute data about the main problems of these newborns.

The files of all home-born infants (66 of 525), who were admitted to our Neonatology Department between June 2000 and May 2001, were evaluated retrospectively. Admitting ages, weights, gestation weeks, complaints, and places of birth of the newborns were reviewed. Furthermore, education levels, occupations, and kinships of parents were recorded.

Twelve and a half percent (66/525) of the reviewed infants was born at home. Admitting weights of infants were recorded between 1050 and 4600g and the mean value was 2891±840 g. The mean admitting age was 8.6 days within a range of 0 to 30 days. Forty-five and a half percent of mothers was illiterate and 9% of fathers was unemployed. During the study period, 19.7% of 66 home-born and 6.5% of 459 hospital-born infants could not be saved. The death reasons among home-delivered babies were sepsis (n=2), hemorrhagic disease of the newborn (n=2), pneumonia (n=1), prematurity with asphyxia (n=5), neonatal tetanus (n=1), and congenital anomalies (n=2).

The high rate of newborn deaths remains an important problem for developing countries. Especially home births enhance the burden of the problem. Low literacy rate of women, high rate of unemployment, and working in unqualified jobs are main characteristics of families who prefer home births. Deliveries with trained persons and appropriate perinatal care will significantly reduce incidence of morbidity and mortality in newborns in developing countries.

P4 THE TIME OF CLAMPING THE UMBILICAL CORD: IS IT IMPORTANT?

A. Orozco^1,2, S. Graham^1,2. ¹Departament of Neonatology, Hospital Angeles del Pedregal, México, DF, Mexico; ²Facultad Mexicana de Medicina, Universidad La Salle, Mexico, DF, Mexico

Since 1930, Haselhorst has reported that the placental rate of transfusion can be important in the newborn and increase the blood volume between 35% and 60%.

At the moment of the delivery, the baby closes the foramen oval, and needs increased pulmonary resistance. If this process is delayed or altered, a good adaptation cannot be obtained. We think that a good blood volume in necessary for normal adaptation to extrauterine life. Ten seconds after the delivery, the baby is transfused with approximately 10 ml/kg. We think that if we retard clamping of the cord by 15 seconds, we can benefit from neonatal adaptation by increasing blood volume.

We made an observational, prospective, double-blind study with 200 term newborns without perinatal incidents, with 100 clamping the cord immediately and in the other hundred 15 seconds after delivery. We recorded the use of supplementary oxygen, cyanosis, and need of incubator.

A hematocrit value was obtained 48 hours after birth.

We obtained two similar groups in weight, Apgar scores, presence of meconium in amniotic fluid, and time required in incubator.

Hematocrit was similar in both groups and no symptomatic policytemia was detected.

We found, in 8/100 patients, delayed clamping of the cord with cyanosis and polypnea that required supplementary oxygen.

In 35/100 patients with immediate cord clamping cyanosis, polypnea and the need for oxygen were recorded.

We think that a 15-second delay in clamping of the cord in term babies can help for a better neonatal adaptation.

This is a cheap procedure that lowers hospital costs in neonatal care.

We did not observe important morbidity or mortality in this study.

P5 NEONATAL AUTOPSY: DOES IT ADD TO OUR CLINICAL DIAGNOSES?

W.J. Kowalski¹, D. Paul², J.S. Greenspan¹, L. Kochilas¹. ¹Pediatrics, Thomas Jefferson University, Philadelphia, PA; ²Pediatrics, Christiana Care, Newark, DE

Studies demonstrate that clinical diagnostic errors are found frequently in neonatal autopsies. The significance of the underdiagnosed or overdiagnosed clinical conditions in the critically ill newborns has not been adequately assessed. Our objective was to determine if neonatal autopsies can identify specific preventable deficiencies in the management of the critically ill newborn. This is a retrospective chart review of a case series of neonatal deaths in a 6-year period in two tertiary care NICUs. The following data were collected: birth weight, gestational age, age at death, clinical diagnoses and cause of death, pathological diagnoses, and cause of death per autopsy report.

We examined 33 cases with an average gestational age of 34 weeks and an average age at the time of death of 9.8 days. The most common clinical causes of death were prematurity (15/33), respiratory failure (11/33), and sepsis (7/33). Other diagnoses included persistent pulmonary hypertension of the newborn and necrotizing enterocolitis (NEC). The most common causes of death per autopsy reports were bronchopneumonia (7/33) and sepsis (4/33). Major clinicopatholgic discordances were detected in 49% of cases. Seven of them (21%) were associated with probable adverse impact on survival (class I): unrecognized respiratory infection is the most frequent condition that leads to death, while heart failure was unexpectedly encountered in two cases (6%). In three of seven cases (42%) with class I diagnoses, NEC was clinically overdiagnosed.

Our data demonstrate that major clinicopathologic discrepancies are common in critically ill neonates with both under- and overdiagnosis. Infectious and cardiovascular conditions are the most common unrecognized entities and NEC is the most commonly overdiagnosed clinical entity with fatal outcomes. A higher index of suspicion for these conditions is required, so that appropriate management may result in improved outcomes.

P6 IS BRAZILIAN NEONATAL RESUSCITATION TRAINING OF VENTILATION ADEQUATE?

R. Guinsburg, M.F.B. Almeida, J.O. Costa, L.M. Freire, Instructors of Neonatal Resuscitation Program. Brazilian Society of Pediatrics, Brazil

The objective of this study is to evaluate acquisition of concepts regarding ventilation of the newborn by pediatricians trained by the Brazilian Neonatal Resuscitation Program (NRP). This cross-sectional study gathered data from 44 neonatal resuscitation courses done across Brazil, from August 2001 to January 2002. A total of 448 pediatricians were studied: 69% female, 36±8 years, graduated for 11±8 years, 37% with previous NRP training. Pediatricians received a standard 8-hour course, according to AAP 2000 guidelines: 2 hours of theoretical and 5 hours of hands-on activities in 1 day. Prior to and soon after training, trainees answered the same test (PRE and POST) with 12 questions about initial steps (IS), 11 about bag and mask ventilation (B&M), 6 about chest compressions (CC), 10 about intubation (INT), and 11 about medication (MED). Performance in each block of questions was assessed. The number of correct answers in the posttest for B&M was compared to other blocks.

The table expresses correct answers for each block. Trainees improved their knowledge regarding all procedures (Chi-square, p<0.00001 for each block). Compared to other blocks, the chance to obtain correct answers for B&M was: B&M versus IS (OR 0.51; 95% CI 0.44-0.59), B&M versus CC (OR 0.69; 0.58-0.82), B&M versus INT (OR 0.76; 0.66-0.88), B&M versus MED (OR 0.95; 0.83-1.08). Performance of trainees on the posttest regarding B&M ventilation was not as good as the observed for initial steps, chest compressions, and intubation. Brazilian format of NRP should be modified in order to give more emphasis to the critical step of neonatal resuscitation: ventilationTable 5

P7 BRAZILIAN NEONATAL RESUSCITATION PROGRAM: FACTORS THAT INTERFERE WITH KNOWLEDGE GAIN AFTER TRAINING

M.F.B. Almeida, R. Guinsburg, J.O. Costa, L.M. Freire, Instructors of the Neonatal Resuscitation Program. Brazilian Society of Pediatrics, Brazil

The objective of this study was to evaluate factors that interfere with optimal posttest performance immediately after neonatal resuscitation (NR) training.

This cross-sectional study gathered data from 60 NR courses done across Brazil from August 2001 to January 2002. Study population was 861 trainees that received a standard 8-hour theoretical and practical NR training, according to AAP 2000 guidelines. Prior to and soon after training, trainees answered the same test (PRE and POST) with 50 questions about key concepts on NR. Data were analyzed by logistic regression (dependent variable ¾ POST score 90%, and independent variables ¾ profession, gender, age, previous NR training, and PRE score).

The table shows distribution of variables. Variables significantly associated with POST 90% were: profession, gender, PRE, and interaction between PRE and profession. Probability to achieve POST 90% was:

• 7% and 40% for male physicians, with PRE, respectively, of 50% and 70%;
• 20% and 54% for male nurses with PRE, respectively, of 50% and 70%;
• 26% and 53% for male students with PRE, respectively, of 50% and 70%;
• 10% and 48% for female physicians with PRE, respectively, of 50% and 70%;
• 26% and 62% for female nurses with PRE, respectively, of 50% and 70%;
• 33% and 62% for female students with PRE, respectively, of 50% and 70%.

After immediate NR training, knowledge gain seems better for undergraduates and nurses compared to physicians, regardless of previous NR training. The Brazilian NRP should be modified in order to address the different health professionals involved in neonatal resuscitation. Table 6

P8 INSTRUCTION OF PEDIATRIC HOUSESTAFF IN NEONATAL RESUSCITATION: BENEFIT OF A REFRESHER COURSE

O. Wilson, L.A. Sielski, J.H. Schneider, T.M. McKee-Garrett, L.J. Hull, C.J. Fernandes. Pediatrics, Baylor College of Medicine, Houston, TX

Pediatric housestaff are often the primary physicians responsible for neonatal resuscitation. These skills are simple, but important given their inherent life-sustaining properties. Pediatric residents receive formal training in neonatal resuscitation at the beginning of residency. The purpose of this study is to further enhance pediatric housestaff training and measure retention of knowledge in the basic concepts of neonatal resuscitation.

At the start of a clinical nursery rotation, pediatric residents and medical students were given a multiple choice written exam on basic instruction from the Neonatal Resuscitation Program (NRP). This exam covered initial resuscitative measures, simple positive pressure ventilation, and chest compressions. It did not cover intubation and drug administration. They then received a 1-hour refresher lecture on basic NRP principles. The lecture was done by a NRP instructor. The exam was then readministered to the trainees. The exam scores were compared and analysis done with regards to level of training. All of the pediatric residents had NRP instruction at the beginning of residency training. The medical students were considered a control group as they had no previous formal NRP training.

Exams were given to 33 pediatric residents and 16 medical students. The upper level residents had lower pretest scores than first year residents and a larger deviation in PRE/POST scores. Exam performance improved for all the residents and students after the NRP refresher lecture. The improvement was statistically significant with p<0.001.

A supplemental NRP lecture is beneficial for all pediatric housestaff. This lecturer appears most beneficial for upper level housestaff, who are a year or more from previous NRP training.

P9 NEONATAL SKIN CARE: CLINICAL OUTCOMES OF THE AWHONN/NANN EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE

C.H. Lund¹, J.W. Osborne², J. Kuller³, A.T. Lane⁴, J.W. Lott⁵, D.A. Raines⁶. ¹Intensive Care Nursery, Children's Hospital Oakland, Oakland, CA; ²Department of Educational Psychology, University of Oklahoma, Norman, OK; ³Intensive Care Nursery, Children's Hospital Oakland, Oakland, CA; ⁴Department of Dermatology, Stanford Hospital, Palo Alto, CA; ⁵College of Nursing and Health, University of Cincinnati, Cincinnati, OH; ⁶College of Nursing, Florida Atlantic University, Davie, FL

Knowledge of skin development and research is important when providing skin care to newborns. Sponsored by the Association for Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the National Association of Neonatal Nurses (NANN), an interdisciplinary team developed an evidence-based neonatal skin care guideline, followed by an evaluation of using the guideline on neonatal skin condition.

Skin condition of newly admitted neonates was assessed over an 8-week period by neonatal nurse site coordinators using a nine-point scale reflecting dryness, erythema, and skin breakdown. Infections, frequency of bathing, and emollient use were noted. The Neonatal Skin Care Guideline was then presented at an educational seminar. Newly admitted neonates over an 8-week period were again assessed at each site after implementation.

Fifty-one site coordinators made 11,468 assessments of 2464 NICU and special care newborns and 356 well newborns. Results revealed significant improvement in skin condition scores over time (F=104.53, p<0.0001) and an interaction of group and time (F=6.69, p<0.0001), indicating that infants with disrupted skin conditions improved as a result of using the skin care guideline. There was an increased use of emollients and decreased frequency of bathing. There were no significant differences between the pre- and postguideline groups in terms of blood cultures.

The AWHONN/NANN Neonatal Skin Care Evidence-Based Clinical Practice Guideline was successfully implemented in 51 nurseries, resulting in improved skin condition in premature and full-term newborns. The results support a wider dissemination of the project's practice guideline for neonatal skin care.

The AWHONN/NANN Neonatal Skin Care Project was funded by an educational grant from Johnson and Johnson Consumer Products, Division of Johnson and Johnson Consumer Companies.

P10 OROMOTOR DYSFUNCTION IN NEONATES: A FEEDING STRATEGY

A. Glover¹, T. Lusk¹, A. Knight², M.M. Perkins¹, C. Bunyapen², J. Bhatia². ¹Rehabilitation; ²Section of Neonatology/Department of Pediatrics, Medical College of Georgia, Augusta, GA

Feeding difficulties are commonly encountered in neonatal nurseries. The oromotor dysfunction is manifested by apnea/bradycardia, coughing, refusal to feed, or clinical aspiration. At our institution, nutritive and nonnutritive sucking and tolerance to feeds are assessed by a therapist; if difficulties are observed, a modified barium swallow to document penetration into the laryngeal vestibule and/or aspiration is performed with thin (regular feedings) or thickened feedings (syrup/nectar or honey consistency) and feeding adjusted. This study was conducted to determine if this feeding strategy was useful in the management of infants with feeding difficulties.

One hundred-three infants with gestational ages 23 to 28 (n=28), 29 to 33 (32), 34 to 37 (16) and >38 (27) weeks were studied at >33 weeks' postconceptional age. The studies were videotaped and reviewed by the speech pathologist in conjunction with the radiologist.

Penetration was observed in 45 (43.6%), 43 (41.7%), and 16 (15.5%) instances with thin, syrup, and honey consistencies, respectively; aspiration episodes were observed in 88 (56%), 46 (29.2%), and 23 (14.6%) instances with the same consistencies, respectively. Most of the clinical symptoms were ameliorated with feedings of appropriate consistency; in some instances, feedings by mouth had to be held for additional time before reassessment.

Penetration and aspiration with thin feedings are common occurrences in neonates with feeding difficulty. There is a decline in problems when thicker consistencies are used. Neonates with feeding difficulty should have their feedings thickened to the next consistency and, if symptoms persist, a modified barium swallow should be performed to determine the appropriate feeding strategy. This approach could lead to a safe and cost-efficient way for feeding neonates with oromotor dysfunction.

P11 EARLY MEASUREMENT OF END-TIDAL CARBON MONOXIDE (ETCOC) IN TERM NEONATES

M. Herschel. Pediatrics, University of Chicago, Chicago, IL

Measurement of ETCOc is an objective technique for diagnosing hemolysis. Neonates in whom severe hemolysis is identified early in life can be treated with intensive phototherapy and may avoid exchange transfusion. Neonates with hemolysis are at risk for significant hyperbilirubinemia.

We measured ETCOc within the first 4 hours of life on consecutive neonates (predominantly African-American) admitted to the General Care Nursery of our inner city hospital in order to identify, in a timely fashion, those infants with significant hemolysis, defined as an ETCOc of 3.0 ppm or greater. Smoking history was obtained by self-report from all mothers. Bilirubin was measured (TcB or stat TsB) if the ETCOc was 3.0 or greater. Those infants with elevated ETCOc and significant hyperbilirubinemia for age in hours (at any time during their hospital stay) had an evaluation consisting of CBC, blood smear, reticulocyte count, and blood type and Coombs' test. If the Coombs' test was negative, quantitative G6PD enzyme activity was measured. The same evaluation was performed for all infants with significant hyperbilirubinemia if they needed phototherapy.

From February 21, 2002 to March 25, 2002, 203 babies were admitted to the nursery and had ETCOc measured; 28 had ETCOc of 3.0 ppm or greater. Of the 28, 12 mothers admitted to smoking. In seven, the mothers denied smoking, but the infants did not have elevated bilirubin. The Coombs' test was positive in two, one of whom had very severe ABO hemolytic disease. G6PD deficiency was diagnosed in 5 of 14 neonates with elevated ETCOc but negative Coombs' test and no history of maternal smoking.

Measurement of ETCOc at the time of routine admission to the General Care Nursery identifies those infants at risk for hyperbilirubinemia regardless of the reason for the hemolysis.

P12 BLOOD TRANSFUSION PRACTICE VARIABILITY IN VERY PREMATURE INFANTS

D. Gerstmann, B. Bloom, R. Clark. Center for Research and Education, Pediatrix/Obstetrix Medical Group, Sunrise, FL

We sought to evaluate the extent of variation in blood transfusion practice across sites within a large multiregional neonatology provider group.

Year 2001 deidentified administrative data were queried to determine blood transfusion frequency by hospital site for neonates 23 to 29 weeks' gestation at birth. Virtual practice groups were created by ordering sites into low, mid, and high thirds based on transfusion frequency expressed as number of transfusion per 1000 patient days. Patient demographic parameters were compared by virtual practice group. Transfusion frequency was analyzed according to gestational age at birth, age following delivery, and virtual practice group.

Sixty-four of 132 sites had >15 patients in the selected gestational age range and were included in the analysis, representing 3093 neonates, 184,464 patient days, and 9465 blood transfusions. Transfusion frequency decreased from 100/1000 patient days for neonates born at 23 weeks, to 25/1000 patient days for neonates born at 29 weeks. Forty-four percent of all transfusions occurred in the first 2 weeks of life. There were no differences between virtual practice groups in gestational age (27 weeks), birth weight (960 g), Apgar scores (5 at 1 minute, 7 at 5 minutes), prenatal steroid use (77%), gender (53% male), or mode of delivery (64% cesarean section). Transfusion frequency by site ranged from 1 to 152 per 1000 patient days. Transfusion frequency was 21, 50, and 80 per 1000 patient days for the low, mid, and high virtual practice groups, respectively, p<0.0001 (ANOVA). In the context of this data set, wide variability existed in transfusion frequency across sites for very premature infants as demonstrated by the large range (>´100) in site transfusion frequency and in the significant increase (´4) in transfusion frequency across virtual practice groups. We speculate that observing, isolating, and implementing meaningful differences between high and low centers (using the Best Demonstrated Process Methodology) will lead to a reduction in transfusions, especially in the high centers.

P13 TRANSFUSION CLINICAL PRACTICE AND ERYTHROPOETIN USAGE IN VERY PREMATURE INFANTS

D. Gerstmann, B. Bloom, R. Clark. Center for Research and Education, Pediatrix/Obstetrix Medical Group, Sunrise, FL

We sought to determine whether transfusion practice or erythropoetin use influenced transfusion frequency of very premature infants in a large multiregional neonatology provider group.

Year 2001 deidentified administrative data were queried to determine blood transfusion and erythropoetin (EPO) use frequencies by hospital site for neonates 23 to 29 weeks' gestation at birth. Virtual practice groups (VPGs) were created by ordering sites into low, mid, and high thirds based on transfusion frequency expressed as number of transfusions per 1000 patient days. EPO use (defined as patients who received any EPO dose) was then evaluated for each VPG.

Sixty-four of 124 hospital sites had >15 patients in the selected gestational age range and were included in the analysis, representing 3093 neonates, 184,464 patient days, and 9465 blood transfusions.

There were no demographic differences between patients in each VPG. Transfusion frequency by site ranged from 1 to 152 per 1000 patient days. Transfusion frequency was 21, 50, and 80 per 1000 patient days for the low, mid, and high use VPGs, respectively, p<0.0001 (ANOVA). EPO exposure was highest in the low transfusion frequency VPG (38% of patients) and lowest in the high transfusion frequency VPG (16% of patients), p<0.0001 (Fisher's Exact Test). However, there was no difference in transfusion frequency between neonates who were or were not treated with EPO within each VPG, i.e., for the low use group: 20 vs 23; mid use group: 51 vs 48; and high use group: 81 vs 79 per 1000 patient days.

Within the context of this data set, wide site variability in transfusion frequency was evident. There was an inverse relationship of EPO use with transfusion frequency across virtual practice groups, but only transfusion practice group and not EPO use influenced transfusion frequency. We speculate that practice mindset, and not the use of EPO, affects transfusion frequency during clinical care of very premature infants.

P14 A METHOD FOR DETERMINING WHETHER TRANSCUTANEOUS BILIRUBIN MEASUREMENTS CAN REPLACE SERUM BILIRUBIN MEASUREMENTS: A MODEL FOR NEW TECHNOLOGY EVALUATION

J.H. Schneider. Pediatrics, Baylor College of Medicine, Houston, TX

Transcutaneous (Tc) measurements of bilirubin correlate well with serum measurements in certain circumstances. A recent Joint Commission on Accreditation of Healthcare Organizations "Sentinal Event Alert" suggests the use of Tc devices. Appropriate evaluations must be made before substituting Tc devices for proven laboratory methods. Statistical correlations and comparisons of means and standard deviations (SD) are inadequate. Instead, confidence intervals (CIs) must be determined for both the mean difference and the range of differences that might be obtained to see if treatment decision errors could occur by using Tc devices.

Tc (BiliChek) and serum bilirubin (Beckman LX-20) measurements were obtained on 28 infants ranging from 1 to 13 days of age who had not received phototherapy. The sample population was 75% Hispanic.

The mean difference between methods was +0.3 mg/dl (Tc>serum). The SD of the differences was 1.0 mg/dl. The correlation between the two methods was 0.946 (p<0.01). The 95% CI of the mean difference was +0.7 to -0.1 mg/dl. The 95% CI of the differences that could result from using this Tc device was +3.0 to -2.5 mg/dl.

Because Tc values may be less than recommended AAP guideline action levels, a decision might be made to use less intervention than would be indicated by a serum level. The risk is relatively small given the CI of the differences and the size (3 mg/dl) of most decision-making ranges in the current AAP guideline. If physicians understand the range of differences that can occur in their patient population, they can adjust to protect against decision-making errors. This would allow safe use of certain Tc devices, which have many benefits over serum measurement methods.

This statistical methodology can also be used in the evaluation of other replacement technologies.

P15 NEONATAL MORTALITY ATTRIBUTED TO KERNICTERUS IN USA

V.K. Bhutani, L.H. Johnson. Newborn Pediatrics, Pennsylvania Hospital, Philadelphia, PA

Adverse outcomes of severe hyperbilirubinemia (total serum bilirubin, TSB, >95th percentile for age in hours) include: acute bilirubin encephalopathy (ABE), posticteric chronic encephalopathy including auditory neuropathy and possibly subtle signs of bilirubin-related neurologic compromise. Death due to kernicterus is extremely unusual and should be unlikely in healthy term babies.

The objective was to review the Pilot Kernicterus Registry (Johnson and Brown, 1992-2002) for neonatal deaths attributed to Kernicterus in term healthy neonates discharged as healthy from well baby nurseries in USA.

Five neonates presented to emergency room (ER) with severe jaundice (Jaun), lethargy, poor feeding, poor responsiveness, arching, and irritability ¾ consistent with ABE. All five died; three within a few hours and others within 3 days of admission. Interventions were: home phototherapy (BM92), intensive phototherapy (five), and exchange transfusions (in two BM93, AM93). The rate of TSB rise (based on last TSB or an estimated cord TSB of 2 mg/dl) was 0.50, 0.36, 0.36, 0.43, 0.25, mg/dl per hour, respectively. Premortem TSB decreased to 19, 96, 11.6 mg/dl (*). Prereadmission features and autopsy confirmation (a) are listed as follows. Table 7

This seemingly unpredictable outcome could have been predicted by a predischarge risk assessment of hyperbilirubinemia (TSB >75th percentile for age in hours) and the subsequent excessive rate of rise in TSB 0.25 mg/dl per hour.

P16 ELECTROENCEPHALOGRAMS IN INFANTS FOLLOWING EXTRACORPOREAL MEMBRANE OXYGENATION: ARE THEY NECESSARY?

J.H. Bartley¹, Y. Park², C. Bunyapen¹, J. Bhatia¹. ¹Department of Pediatrics/Section of Neonatology; ²Department of Neurology, Medical College of Georgia, Augusta, GA

The practice of obtaining electroencephalograms (EEGs) on infants treated with extracorporeal membrane oxygenation (ECMO) was begun to monitor for potential ECMO complications. EEG use is supported by the fact that these patients have altered cerebral blood flow during ECMO cannulation, and that they frequently exhibit signs of neurological impairment after ECMO including lethargy, hypotonia, feeding difficulty, and occasional seizure activity. However, it has been our experience that patients who do not exhibit seizure activity prior to ECMO rarely experience seizures after ECMO. As a result, we attempted to determine if the use of post-ECMO EEGs, especially in the infant without clinical seizure activity, results in changes in clinical treatment.

We performed a retrospective chart review of 54 patients who have undergone ECMO and EEG at our institution over the last 6 years.

Fifteen percent (8 of 54) had evidence of clinical seizures; four of these had normal EEGS, four had focal findings. Six of these eight were discharged on antiepileptic drugs (AEDs); two were taken off of AEDs based on the EEG findings. Eighty-five percent (46 of 54) had no clinical seizure activity; 56% (26 of 46) of these had normal EEGs; 44% (20 of 46) had abnormal EEGs: eight had focal abnormalities, seven had background abnormalities consistent with either age of hypoxic injury, three had focal and background abnormalities, and two had electrographic seizures. Both patients with electrographic seizures were discharged on AEDs.

Forty-four percent of post-ECMO patients had abnormal EEGs. In addition, 2 of 46 patients without clinically observed seizures were treated with AEDs based on EEG results. Likewise, in two patients who had possible clinical seizures, post-ECMO EEG resulted in the cessation of AEDs. Further study to determine the relationship between long-term outcome and post-ECMO EEGs is needed before we abandon the current practice.

P17 PRENATAL MOLECULAR DIAGNOSIS OF CONGENITAL LONG QT SYNDROME

D.J. Tester¹, J. McCormack², M.J. Ackerman¹. ¹Pediatric and Adolescent Medicine/Pediatric Cardiology, Mayo Clinic, Rochester, MN; ²Pediatric Cardiology, Pediatric Cardiology Associates, University of South Florida, St. Petersburg, FL

The earliest possible clinical manifestation of congenital long QT syndrome (LQTS) is fetal bradycardia. However, fetal bradycardia in the setting of maternal -blocker therapy is difficult to interpret. In this setting, strategic genotyping based upon gene-specific arrhythmogenic triggers may enable a precise prenatal molecular diagnosis of LQTS.

Strategic genotyping directed by a swimming-triggered cardiac event was performed on a three-generation family with clinically diagnosed LQTS in which the affected mother was pregnant. KVLQTI-specific mutational analysis using denaturing high-performance liquid chromatography and direct DNA sequencing was performed on DNA derived from peripheral lymphocytes in the fetus' sister (proband). Because of advancing maternal age, an amniocentesis was performed at 16 weeks estimated gestational age. From the amniocentesis, amniocytes were cultured and DNA was isolated. Four weeks later, fetal bradycardia was documented.

In the proband, mutational analysis of KVLQTI revealed abnormal elution profiles in 3 of 16 exons (exons 12, 13, and 16). Direct DNA sequencing demonstrated two common polymorphisms: T>C intron (exon 12), and Y662Y (exon 16), and a novel putative LQTS-causing missense mutation, R539W (exon 13). This mutation was absent in 400 reference alleles.

R539W was confirmed in the proband's mother and maternal grandmother. Moreover, the R539W-KVLQT1 mutation was detected in the fetus. Haplotype analysis confirmed that the amniocyte-derived DNA was fetal in origin. Postnatal genetic testing reconfirmed the R539W mutation.

To our knowledge, this is the first reported case of a prenatal molecular diagnosis for LQTS. Here, the strategic genotyping clarified the etiology of the observed fetal bradycardia: fetal LQTS rather than maternal -blocker effect.

P18 EFFECT OF FETAL BETAMETHASONE EXPOSURE ON LEFT CARDIAC FUNCTION OF VERY LOW BIRTH WEIGHT INFANTS (VLBWI)

T.L. Yokoyama. Pediatrics, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan

Preterm betamethasone treatment induced maturation on the lung and prevented respiratory distress syndrome on VLBWI. We thought that fetal betamethasone treatment might influence other tissues. So we studied the effect of fetal betamethasone exposure on the left cardiac function of VLBWI.

Cardiac function was assessed in 40 infants admitted to the neonatal intensive care unit. Their birth weight was less than 1500 g without inotropic agents. Group 1 consisted of 24 infants with fetal betamethasone treatment. Group 2 consisted of 16 infants without fetal betamethasone treatment.

We performed analysis by using echocardiographies; two dimension, M-mode. Blood pressure was measured by Dinamap oscillometry. Pulse wave was recorded on femoral artery. End-systolic pressure (ESP) was calculated by the blood pressure and the pulse wave. Left ventricular (LV) end-systolic dimension (Des), LV end-diastolic dimension (Ded), end-systolic wall thickness (hes), and LV ejection time were measured from the M-mode echocardiogram. End-systolic wall stress (ESWS) and rate-corrected mean velocity of circumferential fiber shortening (mVcfc) were calculated according to the method of Colan et al. We underwent the study at 12, 24, 48, and 96 hours after birth. We used statistical analysis by ANOVA and an unpaired t-test. Statistical significance was defined as a p value <0.05.

ESWS in Group 1 was significantly lower than in Group 2 at 12 hours. (Group 1 versus Group 2: 12 hours, 24.7±1.4 vs 32.0±2.4; 24 hours, 34.7±2.5 vs 38.4±2.6; 48 hours, 33.2±1.8 vs 36.3±2.5; 96 hours, 30.4±1.5 vs 35.9±3.0; mean±SE, g/cm².) There was no difference between Groups 1 and 2 on mVcfc, Ded, Des, and hes at every study point. ESP in Group 1 was significant lower than in Group 2 only at 96 hours.

We recognized that the contractility in Group 1 had more reserved strength than in Group 2 because ESWS in Group 1 was lower than in Group 2. Fetal betamethasone exposure might influence the decline of the afterload in VLBW. Therefore, we believed that we managed the circulation more easily in VLBWI with fetal betamethasone treatment (Figure 2).

P19 PH DOES NOT EFFECT NITRIC OXIDE SYNTHASE ACTIVITY AND EXPRESSION IN BOVINE AORTIC ENDOTHELIAL CELLS

S. Nagy¹, M.B. Harris², H. Ju², J. Bhatia¹, R.C. Venema^1,2. ¹Section of Neonatology, Department of Pediatrics; ²Vascular Biology Center, Medical College of Georgia, Augusta, GA

Nitric oxide (NO) plays an important role in the fall in pulmonary vascular resistance (PVR) after birth. Delayed relaxation of PVR may result in persistent pulmonary hypertension (PPHN). In animal studies, alkalization has been shown to decrease PVR. Clinically, NO, alkalinization, and ECMO, among others, are used in the treatment of PPHN. We examined the effect of pH on the activity and expression of endothelial nitric oxide synthase (eNOS) as a possible mechanism for the pH-dependent decrease in PVR.

Bovine aortic endothelial cells (BAECs) were exposed to a pH gradient of 7.1 to 7.6 for 4 or 16 hours. Western blotting technique was used to detect expression of eNOS. Activity was measured indirectly by using bovine aortic smooth muscle cells as markers of NO-stimulated cGMP production. Measurements were made at 30, 60, 90 minutes and at 2, 3 and 4 hours. eNOS expression did not change with either the pH gradient or the duration of exposure. cGMP concentrations remained at baseline activity of 1 to 9 fmol/well observed in these cells.

In BAEC, expression and activity of eNOS did not demonstrate pH-dependent changes. These results suggest that clinically observed pH-dependent vasodilatation does not appear to be directly mediated through the induction of eNOS and ,therefore, NO production (Figure 3).

P20 NEONATAL TIDAL VOLUME ON HIGH-FREQUENCY OSCILLATORY VENTILATION USING HOT WIRE ANEMOMETRY

W.J. Sturtz, S.M. Touch, R.G. Locke, J.S. Greenspan, T.H. Shaffer. Neonatology, Thomas Jefferson University Hospital, Philadelphia, PA

The use of high-frequency oscillatory ventilation (HFOV) is increasing due to concern over lung protective strategies in neonates. Theory suggests that HFOV utilizes facilitated diffusion rather than bulk flow of gases to achieve adequate ventilation, and that tidal volume (V_T) in HFOV is less than dead space (V_D), unlike conventional ventilation in which V_T is greater than V_D. Although lung-protective strategies strive for V_T of 4 to 6 ml/kg, physiologic V_T is estimated at 7 to 8 ml/kg; one-third is V_D. Unfortunately, HFOV does not provide in-line monitoring. In vitro and in vivo laboratory studies have shown that hot wire anemometry can accurately measure V_T, rate (f), and [(V_T/kg)²´f] (high-frequency minute ventilation, HFMV) and reflect HFOV performance. These studies indicate that HFOV is load-sensitive and that HFMV correlates with ventilation.

Five infants on HFOV (SensorMedics 3100A) with chronic lung disease and without air leak were enrolled (0.99±0.11 kg). V_T/kg, f, and HFMV were recorded using hot wire anemometry (Florian: Acutronic Medical Systems) around suctioning, and changes in position or ventilator settings. HFOV settings were MAP (12-19 cm H₂O), amplitude (18-40 cm H₂O), f (8-12 Hz), and inspiratory time (0.33).

All infants tolerated this device. The staff found it easy to use and no adverse events were reported. Infants were monitored for 8 hours over 1 to 3 days. Mean V_T/kg ranged from 34.4 to 106.5 (ml/kg)²´ seconds and 1184.7 to 1901.6 ml/min per kilogram, respectively. Effective CO₂ elimination seemed to correlate best with HFMV.

These data indicate that measured V_T/kg during effective HFOV is equivalent to, if not greater than, expected V_D. This is contrary to the belief that ventilation with HFOV is achieved with V_T smaller than V_D. Hot wire anemometry may be helpful in correlating optimal V_T with ventilation during HFOV, and may be useful in decreasing the need for blood gases to assess ventilator-patient interaction.

P21 LATE SURFACTANT ADMINISTRATION IN RESCUE THERAPY DOES NOT AFFECT OUTCOME

F. Vega, I.E. Garcia, L. Garcia, M. Valcarcel. Department of Pediatrics, Neonatology Section, University of Puerto Rico School of Medicine, San Juan, PR

The outcome of patients after different timings of surfactant administration has been compared in scientific reports. There is some evidence that the earlier the administration of surfactant, the better the respiratory outcome. In cases where prophylaxis therapy is not available, the impact of delayed rescue therapy is unknown. We compared the outcome of newborns that received surfactant as rescue therapy during the first 3 hours of life (early) and after 3 hours of life (late).

We reviewed retrospectively all very low birth weight (VLBW) neonates who received surfactant therapy for hyaline membrane disease from January 1999 to December 2001. Data were obtained from the Vermont-Oxford network data form in our center. The study groups were established according to timing of surfactant administration. Outcomes were compared.

There were a total of 253 VLBW neonates who received rescue surfactant therapy. Thirty-seven patients were included in the early therapy group and 167 patients in the late therapy group. No statistical significant difference was found between groups in gestational age, pneumothorax, intraventricular hemorrhage Grades III and IV, periventricular leukomalacia, bronchopulmonary dysplasia, chronic lung disease, and survival. Marginally statistical significant difference (p=0.07) was seen in mean birth weight, with a mean 100 g higher in the late surfactant group. Newborns in the early surfactant group had a higher incidence of retinopathy of prematurity (ROP) Grades III and IV (p=0.004).

In patients requiring surfactant rescue therapy, delayed administration is not associated with a worse pulmonary or survival outcome. The increased risk of retinopathy of prematurity in this group of patients should be further evaluated.

P22 EARLY INDOMETHACIN PROPHYLAXIS IS ASSOCIATED WITH AN INCREASED RISK OF BRONCHOPULMONARY DYSPLASIA IN EXTREMELY LOW BIRTH WEIGHT INFANTS

D. Freysdottir, S.E. Hegemier, P.L. Ramsay. Department of Pediatrics, Baylor College of Medicine, Houston, TX

Indomethacin is an inhibitor of prostaglandin synthesis and is an effective treatment of patent ductus arteriosus (PDA). Prophylactic therapy for PDA with indomethacin has become customary in the care of extremely low birth weight (ELBW) infants. Reports of an association between antenatal exposure to indomethacin and the subsequent development of neonatal side effects, such as bronchopulmonary dysplasia (BPD), necessitates further assessment of potential morbidities associated with early postnatal exposure to indomethacin.

We tested the hypothesis that early postnatal exposure to indomethacin would be associated with an increase the incidence of BPD in extremely low birth weight infants.

This study was a part of an ongoing investigation for clinical markers for the development of BPD. We enrolled 185 infants with a birth weight less than <1000 g admitted to Texas Children's Hospital between June 1997 and December 2001, intubated for respiratory support, and treated with exogenous surfactant. Infants with congenital infections or anomalies were excluded. Infants were divided into two groups ¾ those who were treated with prophylactic indomethacin and those who were not. Infants were evaluated for the development of BPD as defined by an oxygen requirement at 36 weeks' postconceptual age.

We observed no differences between gestational age, birth weight, or death in the first month of life between the infants who were exposed to early postnatal indomethacin and those infants that who not. BPD occurred in 77% of infants who were exposed to early indomethacin, versus 62% of those not exposed (p<0.025).

These results suggest that early postnatal exposure to indomethacin may increase the relative risk for the development of BPD in these ELBW infants.

Larger studies are warranted to detect subtle differences in these ELBW infants.

P23 INDOMETHACIN THERAPY IN PREMATURE INFANTS: EFFECTIVENESS OF A DOSING STRATEGY BASED ON A SINGLE MEASUREMENT OF A SECOND DOSE PEAK SERUM INDOMETHACIN CONCENTRATION

D.J. O'Donovan, C.J. Fernandes, N.Y. Nguyen, K. Adams, J.M. Adams. Pediatrics, Baylor College of Medicine, Houston, TX

Indomethacin (INDO) is the most frequently used pharmacological agent for closure of a patent ductus arteriosus (PDA) in premature infants. The value of plasma serum INDO concentration monitoring remains controversial.

A retrospective study to determine the effectiveness of a standardized adjustable INDO dosing strategy, based on a single peak serum INDO concentrations obtained after two initial doses of 0.2 mg/kg, IV, every 12 hours. The medical records of 103 infants (BW 867±224 g and GA 26.3±4 weeks), who were treated with INDO for a PDA had second peak serum INDO concentrations and followed guidelines for INDO dosing adjustments over a 4-year period (1995-1998), were reviewed. Treatment success, patient demographics, and clinical outcomes were evaluated.

Of the 103 infants treated with the INDO dosing strategy, 66 (64%) achieved PDA closure while 37 (36%) did not. No differences in second dose peak serum INDO concentrations (830±339 vs 816±382 ng/ml), DOL of treatment (4±1 vs 4±2), or number of INDO doses (4±1 vs 4±2) were observed between responders and nonresponders. However, fourth dose peak serum INDO concentrations, available from 54% of the responders and 53% of the nonresponders, were lower in nonresponders (1496±339 vs 1828±606 ng/ml, p<0.5). No evidence of INDO toxicity was observed in either group. Patient demographics and neonatal morbidities were similar between groups.

Using a standardized adjustable INDO dosing strategy, based on a single measurement of a second dose peak serum INDO concentrations, PDA closure rates of 64% with minimum toxicity can be achieved. However, fourth dose peak serum INDO concentrations were lower in nonresponders, suggesting that suboptimal INDO dosing contributed to treatment failure in these infants.

P24 EVALUATION OF A NEONATAL VANCOMYCIN DOSAGE REGIMEN

M.A. Fisher¹, A.L. Mitchell^1,2, K.L. Vo³, M. Sandoval¹. ¹Pediatrics, Albany Medical College, Albany, NY; ²Pharmacy, Albany Medical Center, Albany, NY; ³IDEC Pharmaceuticals, San Diego, CA

Questions remain as to the optimal dosing of vancomycin in neonates, particularly in the very premature. Our objective was to validate our neonatal vancomycin dosage regimen (see table). An IRB-approved retrospective chart analysis was performed for neonates receiving vancomycin per our dosage regimen from 1996 to 2000. Patients were excluded if either peak or trough levels were unavailable. Data were collected for Group 1 (<28 weeks), Group 2 (28-34 weeks), and Group 3 (>34 weeks): patient demographics, infection risks, vancomycin serum levels, and risks for renal impairment. Effectiveness was defined as percent of therapeutic peak (20-40 mg/l) and trough levels (5-15 mg/l).

Fifty-nine patient courses were included. Most patients received 10 days of therapy for sepsis. Majority of patients had at least one risk factor for infection. Group 1 had highest risk for poor vancomycin clearance (45% patent ductus arteriosis, 55% on renal toxic drugs, 45% birth asphyxiation and 27% renal dysfunction). All groups had at least 60% efficacy for trough levels (similar for peaks except Group 3, which had 29%). Efficacy rates were not affected when patients with renal dysfunction were eliminated.

This regimen appears to be effective in achieving desired peak and trough vancomycin levels in most patients, despite risks for renal dysfunction and extreme prematurity. Table 8

P25 INCREASED IL-6, IL-1, AND IL-8 IN CORD BLOOD OF TERM NEONATES COMPARED TO ADULT CONTROLS IN RESPONSE TO BACTERIAL ANTIGENS

M.A. Mohamed¹, F. Cruz¹, C. Dean², S. Cunningham-Rundles¹, M. Nesin¹. ¹Department of Pediatrics, Cornell University Weill Medical College, New York, NY; ²Wyeth Research, Pearl River, NY

Production of proinflammatory cytokines is one of the neonatal host defense mechanisms against bacterial infection. Overproduction of these cytokines may play a role in the inflammatory processes that are responsible for the development of bronchopulmonary dysplasia and periventricular leukomalacia. To study these proinflammatory cytokines (IL-6, TNF-alpha, IL-1, and IL-8), in vitro production from fresh cord blood samples of healthy term neonates was compared to adult controls using common neonatal pathogens.

Blood samples were diluted in RPMI 1640 and cultured with different activators (Group B Streptococcus (GBBS) and E. coli) for 4 hours at 37 °C in a humidified incubator with 5% CO₂. These samples were then processed at 0, 1, 2, and 4 hours to assess production of different cytokines (IL-6, TNF-alpha, IL-1, and IL-8) using chemiluminescent immunometric automated assay.

Cord blood samples from 16 neonates and 11 healthy adults were analyzed. In vitro stimulation with GBBS showed significant increase in levels of IL-6, IL-1, and IL-8, detected at 2 and 4 hours of incubation in cord blood versus control (see table). Stimulation with E. coli showed only significant increase in levels of IL-1 at 2 hours (p=0.012) and 4 hours (p=0.013) and IL-8 at 2 hours (0.003) and 4 hours (p=0.0001) of incubation in the cord blood versus control.

Response of cord blood to microbial activators is different from that of adult controls and is characterized by an increase in IL-6, IL-1, and IL-8 production. Table 9

P26 LATE-ONSET COAGULASE NEGATIVE STAPHYLOCOCCUS SEPSIS IN VERY LOW BIRTH WEIGHT INFANTS

E.I. Ahmed, A.A. Johnson, D. Kumar, D.M. Super, N. Abughali, F.A. Saker. Pediatrics, MetroHealth Medical Center, Cleveland, OH

Late-onset sepsis is common (about 25%) amongst very low birth weight (VLBW) infants of which coagulase-negative Staphylococcus [CoNS(+)] sepsis represents a significant proportion (55%).

A chart review of VLBW infants (June 1996 to December 2000) was performed. Infants (BW£1500 g) with a blood culture positive for CoNS(+) were included except when they were asymptomatic and untreated or had more than one CoNS species. The control group [CoNS(-)] were randomly selected VLBW infants from the same period.

Of the 711 VLBW infants, 74 (10.4%) had CoNS(+) sepsis with clinical course: age at onset 16.8±11 days, days to clear bacteremia 5.9±4.3, repeat positive cultures 40.5%, duration of antibiotic(s) 13.5±5.9 days, meningitis 10.4%, and recurrent CoNS(+) sepsis 14.8%. CoNS(+) infants versus CoNS(-) (n=99) had lower birth weight (971±279 vs 1094±286 g, p=0.008) and gestation (27.8±2.6 vs 29.9±3.1 weeks, p<0.001), higher SNAP (14.5±6 vs 12.3±6, p=0.019), and were less likely to be of female gender (41.3% vs 59.4%, p=0.013) or small for gestation (24% vs 45%, p=0.04). CoNS(+) infants were also different (p<0.001) from the control group for duration (days) of: hospital stay (71±30 vs 56±36), TPN (29±18 vs 18±15), central line (9.3±8 vs 5.5±6.8), oxygen supplementation (55±35 vs 37±44), and ventilatory support (21.5±21 vs 12±23). CoNS isolates had the following sensitivity pattern: cefazolin/cephalothin 5.5%, clindamycin 35.1%, gentamicin 18.8%, oxacillin 6.8%, rifampin 78.6%, and vancomycin 100%.

(1) Although VLBW and prematurity are risk factors for CoNS (+) sepsis, female gender, and SGA at birth appear to be protective. (2) More acutely ill infants (higher SNAP) develop CoNS(+) sepsis and subsequently require more support. (3) Resistance to common antibiotics is high and continued use of vancomycin as the principle agent for treatment of CoNS(+) is justified.

P27 NEONATAL MORBIDITY AND MORTALITY FOR INDIA AND THE ROLE OF BACTERIAL SEPSIS (IN 2000)

V.K. Paul, A.K. Deorari on behalf of National Neonatology Forum, India

National Neonatology Forum of India established a voluntary reporting to a prospective database (NNPD) to study patterns of neonatal-perinatal morbidity and mortality at leading academic tertiary centers of India. We evaluated the role of perinatal sepsis on neonatal mortality (NMR) and morbidity.

Sixteen participating centers of the NNPD network prospectively collected demographic and clinical information on every newborn until death or discharge using standardized forms, definitions, and coding. Bacterial isolates from infants with sepsis and the respective antibiotic sensitivity pattern were obtained.

In 2000, there were 51,905 live births (LB) and 1941 were stillbirths; the remaining 41,964 were inborn. There were 3831 outborn babies (to 10 centers). Of the 909 positive blood culture results (in 41.4% of babies with sepsis), bacterial isolates were: Klebsiella (31.2%), Staphylococcus aureus (17.5%), E. coli (10.5%), and C. albicans (8.7%).

Sensitivity to penicillin and ampicillin were low. Prevalence of sepsis was higher in the outborn babies but with a similar pattern of isolates and sensitivities. Table 10

This database encompasses a diverse, multiethnic, and multicultural population from 16 different Indian states. The high NMR due to prematurity and asphyxia was significantly compounded by sepsis (predominantly Gram-negative). Inordinant burden of sepsis was more evident in outborn babies.

P28 FUNGAL INFECTION IN THE VERY AND EXTREME LOW BIRTH WEIGHT INFANT

L.M. Rodriguez, I.E. Garcia, J. Vazquez, L. Garcia, M. Valcarel. Neonatology Section, Department of Pediatrics, University of Puerto Rico School of Medicine, San Juan, Puerto Rico

Fungal infection is an important complication in the neonatal intensive care units (NICU) with high morbidity and mortality especially in the very low birth weight (VLBW) and the extreme low birth weight(ELBW) neonates. This study evaluates risk factors and associated complications in infants with fungal infections.

Data were obtained using the Vermont Oxford Network data forms from 1999 to 2001. Fungal infection was defined as a positive culture for fungi in blood, urine, and/or cerebrospinal fluid. Statistical analysis included t-test and Pearson's Chi-square.

A total of 436 VLBW infants were admitted to the NICU. Fungal infection occurred in 39 (8.9%) patients. Infants with fungal infection had a lower birth weight (957 vs 1123 g, p=0.0001) and gestational age (28 vs 29 weeks, p=0.004). The hospital course of patients with fungal infection was complicated with bacterial sepsis (41% vs 19%, p=0.0012), Gram-positive sepsis (44% vs 16%, p=0.0000), necrotizing enterocolitis (NEC) (41% vs 12%, p=0.0000), retinopathy of prematurity (ROP) Grades III and IV (16% vs 4%, p=0.0303), and chronic lung disease (CLD) (28% vs 13%, p=0.0004).

In the ELBW group consisting of 166 patients, 25 (15.0%) patients had fungal infection. There was no difference in birth weight, gestational age, and mode of delivery. The hospital course of patients with fungal infection was more commonly complicated with bacterial sepsis (40% vs 17%, p=0.0082), Gram-positive sepsis (56% vs 19%, p=0.0001), and NEC (40% vs 17%, p=0.0082). In this group, there was no difference in CLD, and ROP Grades III and IV.

Fungal infections are more prevalent in the smallest and more premature babies as demonstrated by our results. The presence of other infections in the ELBW suggests that prematurity and birth weight were not the sole risk factors for fungal infection. Deficiency of immunologic factors may play an important role in the pathogenesis of the disease.

P29 COMPREHENSIVE INFECTION CONTROL MEASURE REDUCE NOSOCOMIAL INFECTION RATES IN A NEONATAL INTENSIVE CARE UNIT

R.L. Schelonka, S. Scruggs, K. Nichols, R.A. Dimmitt, W.A. Carlo. Pediatrics, University of Alabama at Birmingham, Birmingham, AL

Nosocomial infections (NI) are a frequent and important cause of morbidity and mortality in newborn infants who receive intensive care. We tested the hypothesis that comprehensive infection control (CIC) measures decrease nosocomial infection rates in a large neonatal intensive care unit.

The study was a single center interventional trial. Demographic and microbiology information for all infants admitted to the NICU from January 1, 1999 to December 31, 2000 established baseline data. The CIC intervention consisted of increasing nursing and physician education and awareness of infection rates, establishing common improvement goals, training in handwashing and environment care, and implementing a specialty nursing team for central venous and arterial catheter care. The intervention period was during January and February 2001. The postintervention period was from March 1, 2001 to March 31, 2002. Main outcome measure was the rate of blood, cerebrospinal, and/or urinary tract bacterial or fungal infections per 1000 hospital days. Baseline infection rate (IR) was 8.5/1000 hospital days and decreased to 5.8/1000 hospital days (Table). Nosocomial infection rate fell to 32% after the CIC intervention. The reduction in total NI was due mostly to a 47% fall in coagulase-negative Staphylococcus (CoNS) infection rate.

Comprehensive infection control measures can reduce bacterial NI rates. This effect is largely due to a 47% reduction in CoNS infections. Table 11

P30 MILD TO MODERATE RENAL DYSFUNCTION DOES NOT ALTER THERAPEUTIC LEVELS OF CAFFEINE IN NEONATES TREATED FOR APNEA OF PREMATURITY

C. Cabrera, M. Frank, D. Carter, J. Bhatia. Section of Neonatology/Department of Pediatrics, Medical College of Georgia, Augusta, GA

Infants requiring caffeine citrate for the treatment of apnea of prematurity (AOP) are also those with an increased risk for renal dysfunction. Approximately 25% of premature infants who weigh less than 2500 g experiences at least one apneic episode during the first 10 days of life and the incidence increases to 90% for those less than 1000 g at birth. Acute renal failure (ARF) varies from 1% to 8% in newborn infants admitted to the Neonatal Intensive Care Nursery. Therapeutic levels of caffeine in premature infants range from 5 to 20 g/ml, with toxic levels being >50 g/ml. No data are available on the effects of renal dysfunction on caffeine pharmacokinetics in these infants.

We conducted a prospective observational study in 30 infants with gestational age ranging from 23 to 34 weeks, who were on caffeine citrate and monitored serum electrolytes, creatinine, and caffeine weekly (from 1 to >6 weeks).

Birth weight ranged from 592 to 1720 g. Serum creatinine levels ranged from 0.1 to 1.9 mg/dl and the caffeine concentration ranged from <5 to 25 g/ml. At the same creatinine concentration, caffeine concentrations varied by as much as 10 g/ml; however, none of the levels was considered toxic (>50 g/ml). Caffeine concentrations were significantly correlated with creatinine (p<0.0001). There was no correlation between BUN and caffeine concentrations.

Despite a wide range in creatinine concentrations from 0.1 to 1.9 mg/dl, caffeine concentrations never reached toxic levels and remained close to the therapeutic range (5-20 g/ml). Despite a statistical correlation between caffeine concentrations and serum creatinine, there appears to be no clinical effect of renal dysfunction on caffeine disposition. We conclude that the use of caffeine in neonates for the treatment of AOP is safe and monitoring levels are unnecessary even in infants with renal dysfunction.

P31 A PROSPECTIVE STUDY EVALUATING THE EFFECT OF IMMUNIZATIONS ON APNEA AND BRADYCARDIA (A&B) SPELLS IN PREMATURE INFANTS

R.C. Lussky, M.L. Sneen, R.F. Cifuentes, K.E. Kaestner, D.K. Abrams, J.S. Geppert. Department of Pediatrics, Hennepin County Medical Center, Minneapolis, MN

Recent literature has purported to show an increased rate and/or severity of A&B spells in premature infants after their first set of immunizations. This study is a prospective evaluation of the change in A&B spells and the overall respiratory status of premature infants after receiving their first set of immunizations containing the current acellular pertussis vaccine.

Fourteen infants were enrolled in this study. For a period of 72 hours preimmunizations and 72 hours postimmunizations, the cardiorespiratory status of each infant was evaluated using documented event monitoring and pulse oximetry. Immunizations consisted of DaPT, IPV, HiB, and PCV7.

Statistical analysis was performed by paired t-tests.

M/F: -7:7, GA: 26.8±2.5 weeks, BW: 964±375 g, corrected GA when immunized: 35.5±2.8 weeks (M±SD), RDS: 93%, BPD: 73%, IVH: 40%, and PVL: 20%. There was no change in A&B spells (frequency, length, lowest heart rate, and needed intervention) or oxygenation status (desaturations [number, length, and needed intervention], baseline oxygenation saturation, and average supplemental oxygen). There was an increased respiratory rate in 50% of the infants from preimmunization status. Fourteen percent and 21% of infants had an increased requirement for nebulizations and supplemental oxygen, respectively, postimmunizations. We did not find any associated changes in the frequency or severity of A&B spells in premature infants associated with immunizations. An unexpected finding was an increase in respiratory rate, not associated with an increased temperature, and an increased requirement for nebulizations and supplemental oxygen postimmunizations. Our findings do not support previously considered recommendations to delay immunizations in premature infants. This study was funded by Mallinckrodt.

P32 PALIVIZUMAB PROPHYLAXIS OF RSV DISEASE ¾ RESULTS OF 5097 CHILDREN ¾ THE 2001 TO 2002 OUTCOMES REGISTRY

M. Hudak, The Palivizumab Outcomes Registry. University of Florida, Jacksonville, FL

The Outcomes Registry is a prospective multicenter study designed to determine demographics and outcomes in infants and children receiving palivizumab and to describe the number of injections, compliance with the prescribed regimen, and seasonality of RSV.

The prospective multicenter study enrolled 5097 infants from 116 sites across the US who received at least one dose of palivizumab after June 1, 2001. Subject demographics, risk factors, injection history, and RSV hospitalizations are recorded.

Gestational ages were available for 5096 infants and children. The subgroup breakdown based on prematurity is: <32 weeks GA ¾ 39.7% (2024), 32 to 35 weeks GA ¾ 49.1% (2502), and >35 weeks GA ¾ 11.2% (570). Of interest, 83% (4233) had a birth weight of <2500 g. Risk factors for severe RSV, consistent with AAP guidelines, included: multiple birth 31.9%, BPD 24%, daycare attendance 14.5%, other household children in daycare 41.3%, and tobacco exposure 20%. Of note, 19% (567) of these children was sick enough to receive palivizumab for a second season. Of those born 32 to 35 weeks' gestational age, 84.3% (2108) had a birth weight <2500 g (mean 2062 g), which is well below the national average of ~2600 g; 54% attended daycare or had a sibling in daycare; 38% (952) was multiple birth; and 20% was exposed to tobacco smoke at home. Additionally, 79% of this subgroup had at least one additional risk factor other than prematurity in keeping with the AAP guidelines.

Clinical practice reporting within the registry shows marked used of palivizumab in low birth weight infants, many of multiple birth, with the majority having important risk factors for RSV disease. The registry continues to provide an opportunity to monitor "real life" palivizumab utilization and clinical decision making in the US.

The Palivizumab Outcomes Registry is sponsored by MedImmune.

P33 SAFETY SURVEILLANCE IN CHILDREN TREATED WITH PALIVIZUMAB (PLV)

E.M. Connor¹, J.B. McClain², M. Sorrentino³, R.L. Hirsch³, F.H. Top, Jr.¹. ¹Clinical Development; ²Pharmacovigilance; ³Medical Affairs, MedImmune, Gaithersburg, MD

PLV (SynagisÒ) is approved for the prevention of serious RSV in high-risk children. Safety and efficacy were established in clinical trials. Postapproval safety surveillance is conducted to monitor for serious adverse events (SAE) as PLV is used in practice.

SAE fatalities reported to FDA 1998 to 2001 were identified, including spontaneous reports and reports from caregivers in postmarketing programs (REACH, Registry). The latter are more like clinical trial data collection. Rates per 1000 were compared to the Phase III trial and population-based rates (CDC Vital Statistics).

An estimated 253,808 infants received >1 million PLV doses. The spontaneous/passive report rate was 1.6 for SAE and 0.3 for deaths. Nonspontaneous reports from REACH (N=19,958) and Registry (N=2,116) were 24.5 and 2.4 for SAE and 3.4 and 2.4 for deaths, respectively. In the IMpact-RSV trial (N=1502), the SAE rate was 475 in PLV and 554 in placebo; mortality rates were 4.0 and 10.0, respectively. The postneonatal (28 days-1 year) mortality rate (adjusted for follow-up interval) based on CDC data is 1.2; 5.7 for prematures <2500 g and 14.5 for <1500 g. A significant portion of SAE (58%) and death reports (55%) for PLV was identified through more active surveillance methodology. No new SAE were identified, except very rare (<1/100,000) reports of anaphylaxis. Mortality rates in PLV recipients obtained from more active programs were comparable to those observed in clinical trials (and population-based data); rates for spontaneous reporting were 8- to 10-fold lower as expected.

Active and passive postmarketing safety surveillance in more than 250,000 infants confirms the prelicensure safety profile of PLV. Most reports came from active surveillance. Other than very rare anaphylaxis, no new SAE were observed. There was no evidence of increased rates of SAE or deaths.

Funded by and/or equity in MedImmune.

P34 DISTINCTIVE DISTRIBUTION OF PATHOGENS ASSOCIATED WITH PERITONITIS IN NEONATES WITH FOCAL INTESTINAL PERFORATION VERSUS NECROTIZING ENTEROCOLITIS

E.W. Coates¹, M.G. Karlowicz¹, D.P. Croitoru², E.S. Buescher¹. ¹Pediatrics, Eastern Virginia Medical School, Norfolk, VA; ²Surgery, Eastern Virginia Medical School, Norfolk, VA

The objective was to determine if differences exist in the predominant pathogens associated with peritonitis due to focal intestinal perforation (FIP) versus necrotizing enterocolitis (NEC). A retrospective cohort study was conducted of neonates with peritonitis due to FIP or NEC over a 12-year study period (1989-2000). NEC was defined by radiologic evidence of pneumatosis intestinalis or portal venous gas, or by pathology reports or surgical operative notes describing large areas of transmural bowel necrosis. FIP was defined as a <1-cm intestinal perforation surrounded by otherwise normal tissue in the absence of NEC findings.

Thirty-six cases of FIP were compared to 80 cases of NEC. Birth weight was significantly lower in infants with FIP (median 772 g; range: 482-4390) compared to NEC (median 1273 g; range: 510-3210), p<0.0001. Gestational age was significantly lower in FIP cases (median 26 weeks; range 23-40) compared to NEC (median 29.5 weeks; range 23-40), p=0.007. Age at intestinal perforation and case fatality rates were similar for FIP and NEC cases. There were striking differences in distribution of predominant pathogens associated with peritonitis in NEC and FIP cases. Enterobacteriaceae were present in 60 of 80 (75%) NEC cases compared to 9 of 36 (25%) FIP cases, p<0.0001. In contrast, Candida species were found in 16 of 36 (44%) FIP cases compared to 12 of 80 (15%) NEC cases, p=0.001, and coagulase-negative staphylococci were present in 18 of 36 (50%) FIP cases versus 11 of 80 (14%) NEC cases, p<0.0001. Stratified analysis for birth weight <1200 g found similar and significant differences in the predominant pathogens for FIP (n=29) and NEC (n=38).

Candida species and coagulase-negative staphylococci were the predominant pathogens in FIP peritonitis in contrast to Enterobacteriaceae in NEC peritonitis.

P35 THE ROLE OF ADAPTIVE MUCOSAL IMMUNITY IN ISCHEMIA/REPERFUSION INTESTINAL INJURY

R.A. Dimmitt¹, H.W. Schroeder², Y. Hammers³, R.L. Schelonka¹. ¹Pediatrics, University of Alabama at Birmingham, Birmingham, AL; ²Medicine and Microbiology, University of Alabama at Birmingham, Birmingham, AL; ³Pathology, University of Alabama at Birmingham, Birmingham, AL

Ischemia/reperfusion (I/R) intestinal mucosal damage is one mechanism in the pathogenesis of necrotizing enterocolitis. We have previously demonstrated that I/R injury is more severe in severe combined immunodeficient mice (RAG1) compared to wild-type mice (WT). We have developed a protocol of bone marrow (BM) transplantation in RAG1 mice, reconstituting adaptive immune function. We tested the hypothesis that the I/R intestinal injury in RAG1 mice could be attenuated following WT BM reconstitution.

We studied three groups: BALB/c WT (n=10), BALB/c RAG1 (n=10), and BALB/c RAG1 reconstituted with WT adult BM (RAG1+WT, n=6). Newborn RAG1+WT mice underwent sublethal conditioning irradiation (10 rad/g) on the third day of life followed by an intraperitoneal injection of 10⁷ adult WT BM cells. At 4 weeks of age, mice underwent superior mesenteric artery occlusion for 60 minutes of ischemia and followed by 90 minutes of reperfusion. The ileum was fixed for microscopic analysis. Histopathologic injury was graded from 0 (no injury) to 4 (transmural necrosis). The animals were categorized as having an injury score £2 (isolated mucosal injury) or 3 (mural necrosis). Categorical data were analyzed using Fisher's exact test, p<0.05.

RAG1 mice had more severe intestinal injury than WT or RAG+WT mice (see table).

Adaptive mucosal immune function protects against I/R intestinal injury. This model allows selective reconstitution of adaptive immune components to understand the mechanisms of protection from this injury. Table 12

P36 IDENTIFYING DYSFUNCTIONAL K⁺ TRANSPORT IN ERYTHROCYTES OF EXTREMELY LOW BIRTH WEIGHT INFANTS WITH NONOLIGURIC HYPERKALEMIA

I. Basaldu-Prado, M.A. Choudary, R. Castro. Pediatrics, University of Texas Health Science Center, San Antonio, TX

Hyperkalemia (HK) develops in 30% to 50% of VLBW infants during the first 24 hours of life and is associated with a 17% to 30% mortality. Since early HK in VLBW infants is not associated with decreased urine output of increased creatinine, the pathogenesis of "nonoliguric" HK may result from intracellular K⁺ that shifts to extracellular plasma. Immature cells, including erythrocytes, may demonstrate dysfunctional K⁺ transport, contributing to increased K⁺ shifts. Decreased Na⁺-K⁺ ATPase activity and higher K⁺ efflux have been measured in immature erythrocytes. Therefore, we measured Na⁺-K⁺ ATPase expression and K⁺ associated volume regulated efflux in erythrocytes from VLBW infants at risk for HK.

Blood samples (~0.1 ml) were obtained at 0 to 24 hours from 30 VLBW infants and cell volume regulation was determined utilizing a Coulter Counter. Erythrocytes were exposed to hypotonic conditions (190 mOsm/kg H₂O) and activating cell swelling to determine the characteristic and presence of Regulatory Volume Decrease (RVD) via stimulated Cl^--dependent K⁺ transport efflux. Protein was isolated from remaining samples to measure Na⁺-K⁺ ATPase expression via Western blot analysis.

The incidence of nonoliguric HK was 45% with a resultant mortality of 53% from various etiologies. MCV values were smaller in HK infants and erythrocyte volumes from HK and non-HK infants exposed to hypotonic media increased by 50% and 30% ,respectively. RVD was not demonstrated in erythrocytes from either group. Na⁺-K⁺ ATPase ₁ protein expression was two-fold greater in erythrocytes from non-HK versus HK patients.

Erythrocytes from VLBW infants with HK have smaller MCV values and demonstrate an immediate alteration in volume regulation and lower Na⁺-K⁺ ATPase expression, corresponding with immature ion transport mechanisms. Altered erythrocyte volume regulation may allow for early identification of VLBW infants at risk for nonoliguric HK.

P37 TOWARD A STANDARD PROTOCOL FOR GLUCOMETER SERIES IN TERM LGA NEONATES

M.M. Subtirelu, Y.G. Verna. Pediatrics, Bronx-Lebanon Hospital Center, Bronx, NY

Screening for hypoglycemia is routinely done in term large-for-gestational age (LGA) neonates. Blood-drawing protocols vary across hospitals and their impact and benefits were never reported. At our hospital, a seven-measurement protocol (1/2, 1, 2, 3, 6, 12, 24 hours) is the standard of care. The objective of our study is to establish a standard protocol that minimizes painful blood drawing and reduces cost.

We reviewed the charts of the term LGA neonate (above 90th percentile on the Colorado Intrauterine Growth Chart) population of our large inner city hospital for two consecutive years. Complete glucometer series, measured with the Precision G blood glucose testing system from Medisense, were collected. Factors such as gestational age, birth weight, mode of delivery, sex, Apgar scores, polycytemia, maternal preeclampsia, and tocolytic use were considered. Hypoglycemia, defined as a blood glucose level below 40 mg/dl detected at any time, was the gold standard for statistical analysis.

Among the 193 LGA neonates, the median birth weight was 4054 g, 24.9% was born by cesarian section, and 39.9% was female. Overall, 36.8% was hypoglycemic within 24 hours of life, 20.7% at 1/2 hour, 16.6% at 1 hour, 7.3% at 2 hours, 4.7% at 3 hours, 3.6% at 6 hours, 2.1% at 12 hours, and 0.5% at 24 hours. The sensitivity of a single measurement decreased from 56.3% at 1/2 hour to 1.4% at 24 hours. The sensitivity different protocols increased with the number of measurements and with earlier screening age. Even though four LGA neonates were hypoglycemic at 12 hours and one at 24 hours, respectively, the relative risk of recurrent hypoglycemia fluctuates with age approaching zero at 6 hours of life.

The incidence of hypoglycemia is highest at 1/2 hour and constantly decreases thereafter. Five consecutive measurements (1/2, 1, 2, 3, 6 hours), with a sensitivity of 95.8%, offer a reasonable and sensitive alternative to other schedules.

P38 VENOUS VERSUS CAPILLARY SAMPLING FOR DETERMINATION OF PLASMA GLUCOSE CONCENTRATIONS IN THE NEWBORN

M.R. Beeram, B. Gary, C. Laughran. Division of Neonatology, Scott and White Clinic/Texas A&M College of Medicine, Temple, TX

Capillary sampling is a common way of measuring glucose concentration in neonates while peripheral venous sampling is the gold standard. Previous studies have small sample sizes and venous and capillary samples were not obtained simultaneously. The objective of this study is to evaluate the accuracy of capillary versus venous samples for glucose determination in the newborn at normal and hypoglycemic levels.

Seventy-three neonates who required routine glucose monitoring were prospectively evaluated. A venous sample was obtained from the antecubital site and a simultaneous capillary sample was drawn from a prewarmed heel. Samples were centrifuged and plasma glucose values measured immediately. Hematocrit values were also measured.

Mean BW and GA were 1669±810 g and 32±4 weeks, respectively. Samples were centrifuged and analyzed within 2.1±1.0 minutes. Capillary glucose values were slightly higher with p=0.04 (73.5±26.4 vs 72.3±26.8 mg/dl) with a difference of 1.2±5.0 mg/dl (95% CL 0.05-2.4) with high correlation (r=0.98). At normal ranges of 40 to 120 mg/dl, there was 97% agreement (95% CL 91-100%). At <40 mg/dl, a critical level for therapeutic intervention, there was 78% (seven of nine paired samples) agreement (95% CL 40-97%). In other two of the nine cases, venous glucose values were 39 mg/dl and capillary values were 40 mg/dl, with a difference of 1 mg/dl. While correlation between capillary and venous hematocrit values was high with r=0.93, capillary values were significantly higher than the venous with p<0.01 (48±12 vs 45±11). Difference between venous and capillary glucose values had poor correlation to hematocrit values (r=0.02).

Capillary sampling is a reliable way of measuring glucose values in neonates. However, at a critical level for therapeutic intervention (<40 mg/dl), a clinician should be aware that reliability decreases. Hematocrit values have no impact on plasma glucose measurements when plasma is separated immediately.

P39 ANTENATAL DIAGNOSIS OF SURGICALLY CORRECTABLE ANOMALIES: ARE REPEATED CONSULTATIONS ANXIETY-INDUCING OR ANXIETY-REDUCING?

L. Aite, A. Trucchi, A. Nahom, A. Zaccara, P. Bagolan. Newborn Surgery Unit, Bambino Gesù Children Hospital, Rome, Italy

Antenatal counselling of surgically correctable anomalies is often offered by several consultations, even in the presence of an experienced perinatal team. However, whether or not such repeated consultations may increase or decrease parental anxiety remains to be determined. Forty-six couples undergoing prenatal consultation after a diagnosis of a surgically correctable anomaly were asked to fill in a questionnaire (Spielberger State-Trait Anxiety Inventory) measuring anxiety levels (AL). Questionnaire was self-administered both at first consultation and at birth. Antenatal counselling was done by a team including: pediatric surgeon, sonographer, obstetrician, and psychologist. Malformations that formed the object of consultations were: 16 diaphragmatic hernias, 13 intestinal atresias, 9 abdominal masses, 8 abdominal wall defects. Number of consultations depended solely on the gestational age at which diagnosis was made: each fetus was followed up at regular 14- to 21-day intervals from diagnosis to birth. AL at birth was then compared with the number of antenatal consultations. Statistical analysis was performed by analysis of variance and by Pearson correlation coefficient. Categorical variables included gender, educational background, and previous abortions.

No statistically significant difference in AL was found (p=0.094) among different malformations. None of the considered variables proved to be an independent predictor of anxiety. A negative correlation (r=-0.688, p<0.001) was found between the number of consultations and the level of anxiety at birth.

There is evidence that repeated antenatal consultations may significantly reduce AL at birth, irrespective of the type of malformation considered; besides any clinical consideration, early antenatal diagnosis should be encouraged in order to increase as much as possible chances of counselling for the prospective parents.

P40 CHARACTERISTICS OF CONGENITAL CYSTIC ADENOMATOID MALFORMATIONS ASSOCIATED WITH NONIMMUNE HYDROPS AND OUTCOME

K. Tsao¹, L. Vu¹, H. Lee¹, D.L. Farmer¹, C.T. Albanese¹, M.R. Harrison¹, R.B. Goldstein². ¹Surgery, University of California, San Francisco, San Francisco, CA; ²Radiology, University of California, San Francisco, San Francisco, CA

Poor outcomes for CCAM are associated with nonimmune hydrops fetalis (NIHF) and large sizes. This study attempts to determine other sonographic features that may correlate with hydrops and characterize features of hydrops that may correlate with outcome.

The medical records and sonograms of prenatally diagnosed unilateral, large CCAM at our institution were reviewed. Sonographic features included left or right side, macro- or microcystic, mediastinal shift, retrocardiac component size, diaphragm position, and mass-thorax ratio (MTR). Features of hydrops included ascites, scalp or skin edema, pleural or pericardial effusion, and placentomegaly.

Thirty-six fetuses were identified: 27 hydropic fetuses and 9 nonhydropic fetuses. Cystic predominance, diaphragm inversion, and MTR 0.60 were significantly associated with hydrops. Forty-one percent of hydropic fetuses had predominantly cystic lesions, while all nonhydropic fetuses were predominantly solid (p<0.05). All hydropic fetuses had inverted diaphragms compared to five of nine of nonhydropic fetuses (p<0.01). Twenty of 27 hydropic fetuses and four of nine nonhydropic fetuses had MTR greater than 60% (p<0.05). All nine nonhydropic fetuses were expectantly managed and survived. In the hydropic group, four fetuses were expectantly managed with no survivors and 21 fetuses underwent fetal therapy with 10 survivors.

Development of NIHF in fetuses with CCAM remains the strongest prognostic factor associated with survival. Sonographic features of CCAM including diaphragm inversion, cystic predominance, and MTR 60% were significantly associated with hydrops. All fetuses antenatally diagnosed with large, unilateral CCAM with signs of hydrops should be sonographically monitored for progressing disease and could benefit from fetal therapy.

(Underline denotes presenting author)

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October/November 2002, Volume 22, Number 7, Pages 594-622

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